Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7693 www.dora.colorado.gov/professions

Application for Approval to Administer MINIMAL SEDATION, MODERATE SEDATION, OR DEEP SEDATION/GENERAL ANESTHESIA—DENTIST

FEES: Deep Sedation/General Anesthesia: $ 150 Moderate Sedation: $ 160 Minimal Sedation: $45 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado.

APPLICANT INSTRUCTIONS Anesthesia Permit Required. Board Rule XIV requires that a dentist be actively licensed and permitted in order to administer minimal sedation, moderate sedation, deep sedation or general anesthesia in the state of Colorado. It is illegal for a Colorado licensed dentist to administer general anesthesia, deep sedation, moderate, or minimal sedation as determined by the definitions in Rule XIV(C), and the elements and patient parameters covered in Rule XIV(B)(2), prior to documenting compliance with the education/training/experience requirements of Rule XIV and receiving approval for the appropriate anesthesia permit from the Colorado Dental Board. Submission of this application does not guarantee issuance of an anesthesia permit. Plan ahead for the time it will take for us to receive all required documents and complete our evaluation, especially if you will be required to complete a clinical on-site inspection as part of the application process. Please note if you are issued an Inspection Permit in order to proceed to the next and final step in the application process (not applicable if applying for a Minimal Sedation Permit), then the Inspection Permit may only be utilized for purposes of completing the Board-approved clinical on-site inspection. You must successfully complete the clinical on-site inspection as a condition of obtaining an anesthesia permit before you may begin administering either moderate sedation, deep sedation, or general anesthesia to patients in this state. Basic Requirements. All applicants must hold an active Colorado-issued dentist or academic license. Other requirements are outlined in section 12-35-140, C.R.S., of the Dental Practice Act, and Board Rule XIV. Both are available online at: www.colorado.gov/dora/Dental_Board. 

All Colorado licensed dentists and academic dentists are automatically authorized to administer: o Local anesthesia; o Analgesia; o Medication prescribed/administered for the relief of anxiety or apprehension to non-pediatric patients, limited to:  A dose of a single drug (no more than the maximum recommended dose) that can be prescribed for unmonitored home use; or  The above plus nitrous oxide; and o Nitrous oxide/oxygen inhalation analgesia in compliance with Rule XIV(G). If you do not intend to administer anesthesia beyond the above listed anesthesia privileges that are included with your Colorado-issued dentist or academic license, you do not need to complete this application.

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The anesthesia provider’s education, training, experience, and current competence must correlate with the progression of a patient along the anesthesia continuum as illustrated in Rule XIV(B)(1).

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The anesthesia provider must be prepared to manage deeper than intended levels of anesthesia as it is not always possible to predict how a given patient will respond to anesthesia.

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The anesthesia provider’s ultimate responsibility is to protect the patient. This includes, but is not limited to, identification and management of any complication(s) occurring during the peri-anesthesia period.

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No dentist shall administer or employ any agent(s) with a narrow margin for maintaining consciousness including, but not limited to ultra-short acting barbiturates, propofol, parenteral ketamine, and similarly acting drugs, or quantity of agent(s), or technique(s), or any combination thereof that would likely render a patient deeply sedated, generally anesthetized or otherwise not meeting the conditions of the definition of minimal sedation or moderate sedation in Rule XIV(C), unless he/she holds a valid Deep Sedation/General Anesthesia Permit issued by the Colorado Dental Board.

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A dentist who elects to engage the services of another anesthesia provider in order to administer anesthesia in his/her dental office is responsible for ensuring that the office meets the requirements outlined in Rule XIV.

Applicant: Keep this page for your records.

07/2016

Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7693 www.dora.colorado.gov/professions

Application for Approval to Administer MINIMAL SEDATION, MODERATE SEDATION, OR DEEP SEDATION/GENERAL ANESTHESIA—DENTIST

FEES: Deep Sedation/General Anesthesia: $ 150 Moderate Sedation: $ 160 Minimal Sedation: $45 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado.

APPLICANT INSTRUCTIONS (Continued) About the Application. This application is to be completed by you and submitted to the Colorado Dental Board. All questions on the application are mandatory, and all supporting documents must be received before the application may be considered. The application forms must be completed in original ink or typed. Keep a copy of the completed application and supporting documents for your records. Application Expiration. Your application will be kept on file for one year from the date of receipt in the Division. Your file and all supporting documentation will be purged if you do not submit required documents and complete your application process in one year. You will need to submit a new application packet and fee after that time. Social Security Number is Required. Effective January 1, 2009, a Social Security Number is required for all licensees. The Division will consider an application to be incomplete when the applicant fails to submit his/her Social Security Number. The Division will consider an application to be incomplete when the applicant fails to submit their Social Security Number. Exceptions are made for foreign nationals not physically present in the United States and for non-immigrants in the United States on student visas who do not have a Social Security Number. These applicants must submit a signed Social Security Number Affidavit in lieu of a Social Security Number available online at: www.colorado.gov/dora/DPO_Update_Contact. Disclosure of Addresses. Consistent with Colorado law, all addresses and phone numbers on record with the Division are public record and must be provided to the public when requested. It is your responsibility to keep your contact information current in our system. Your email address is not open to public record, but must be provided on this application. Any requests for additional information, license/permit information and renewal notices will be emailed to the email address on record. If your email address is not current, it is possible you will not receive important information from the Division. You can change your contact information online by using Online Services at: www.colorado.gov/dora/licensing. Checking Your Application Status. Visit Online Services at: www.colorado.gov/dora/licensing to track your application from the date we log it in our database to the date your permit is emailed to you as a PDF for printing. Please allow us enough time to receive the application through the mail and enter your application into our database before you check the website. We recommend waiting at least 10 business days from date of mailing before checking the status of your application. Expiration of Permit. Once granted, your anesthesia permit is valid for five years from the date it is issued to you. Although Board staff will attempt to contact you for renewal (through email), it is your responsibility to timely renew your anesthesia permit. Renewal of a permit is only available to those licensed dentists actively administering anesthesia in Colorado. It is recommended that you start the renewal process within the three months prior to the expiration date of your permit rather than waiting to do so during the three month grace-period after the expiration date of your permit.

Applicant: Keep this page for your records.

07/2016

Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7693 www.dora.colorado.gov/professions

Application for Approval to Administer MINIMAL SEDATION, MODERATE SEDATION, OR DEEP SEDATION/GENERAL ANESTHESIA—DENTIST

FEES: Deep Sedation/General Anesthesia: $ 150 Moderate Sedation: $ 160 Minimal Sedation: $45 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado.

APPLICANT CHECKLIST All Applicants: To apply for approval (authority) to administer minimal sedation, moderate sedation, deep sedation, or general anesthesia: Note: You may apply for only one anesthesia permit category with this application. Complete the attached application. Submit the completed application and all supporting documentation to the Colorado Dental Board, including appropriate fee. All fees are non-refundable and subject to change every July 1st. Provide documentation of any name change. If your name has changed since you obtained a previously-issued license, or if your name is different on any of your supporting documentation, you must provide a copy of the legal document verifying the name change (i.e., marriage license, divorce decree, or court order). Submit proof of life support certification. Submit proof of current Basic Life Support certification (BLS) for healthcare providers that meet the requirements of Rule III(G)(7). Also, successful completion of Pediatric Advanced Life Support (PALS) training and continuous certification is required for a dentist that applies for and/or maintains a Pediatric Designation on his/her permit; administering to patients under 12 years of age. Any dentist applying for a Moderate Sedation Permit or a Deep Sedation/General Anesthesia Permit must submit proof of current Advanced Cardiac Life Support (ACLS) certification if administering to patients 12 years and older. It is the dentist’s responsibility to maintain current BLS and ACLS and/or PALS certification at all times. Include appropriate documentation of your education/training/experience as outlined in the Education/Training/Experience Qualifications section of the application for the anesthesia permit level for which you are applying. If you are applying for a Moderate Sedation Permit or a Deep Sedation/General Anesthesia Permit (not required for a Minimal Sedation Permit, unless a “Yes” response is provided to any of the screening questions, which then means your application must be reviewed by the Board): Review the Anesthesia Application Consultant Committee and the Board’s meeting schedule at: www.colorado.gov/dora/Dental_Board and click on “Calendar/Events” under the “Program Information” section of the main page for agenda cutoff deadlines and meeting dates, times, and locations for when your application may be considered since your application must be reviewed by both the Committee and the Board due to your clinical on-site inspection requirement.  Note: Applications will first be reviewed by the Committee and its recommendation will be reviewed by the assigned Board panel at its next scheduled meeting. Panel B is currently reviewing anesthesia applications. Panel A will review anesthesia applications January 1st through December 31st of the calendar year 2017 and Panel B will review them for the following calendar year in 2018. The review schedule will alternate accordingly in subsequent calendar years. Obtain Board approval of your education/training/experience, after which you will be issued an Inspection Permit for up to 90 days to allow you to complete a clinical on-site inspection. 

Note: An Inspection Permit is only for a one-time clinical on-site inspection and cannot be used to administer anesthesia freely.

Arrange for an anesthesia inspection in compliance with Rule XIV(L). Provide the applicable Inspector Report Form (available at www.colorado.gov/dora/Dental_Board, click on “Find Applications & Forms” under the “Licensing Services” section of the main page) and a copy of Board Rule XIV to the Inspector. The Inspector must return the completed Inspector Report Form directly to the Board (please feel free to keep a copy for yourself in case it is required by another organization, i.e. your specialty society for purposes of certification or re-certification with them) along with a copy of the complete anesthesia record for each case observed. A submitted anesthesia record must be in compliance with the documentation requirements of Rule XIV(O).

Submit the completed application below and all supporting documentation to: Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350 Denver, CO 80202 Applicant: Keep this page for your records.

07/2016

Application for Approval to Administer MINIMAL SEDATION, MODERATE SEDATION, OR DEEP SEDATION/GENERAL ANESTHESIA—DENTIST

Division of Professions and Occupations Colorado Dental Board—Anesthesia 1560 Broadway, Suite 1350 Denver, CO 80202 (303) 894-7691 / Fax (303) 894-7693 www.dora.colorado.gov/professions

FEES: Deep Sedation/General Anesthesia: $ 150 Moderate Sedation: $ 160 Minimal Sedation: $45 Fees may be paid by a check or money order drawn in U.S. dollars on a U.S. bank and made payable to State of Colorado.

The content of this application must not be changed. If the content is changed, the applicant may be referred to the Colorado State Attorney General’s Office for violation of Colorado law. Colorado Dentist License Number:

Expiration Date:

Anesthesia permit level for which you are applying (check only one; complete the applicable part of the application listed for the required education/training/experience qualifications): Minimal Sedation Permit—Part 3 Moderate Sedation Permit—Part 4 Deep Sedation/General Anesthesia Permit—Part 5 If applying for a Pediatric Designation on the above anesthesia permit, then also check the following box and complete the applicable part of the application: Pediatric Designation—Part 6; required if planning to administer to patients under 12 years of age PART 1—APPLICANT INFORMATION Name: First:

Middle:

Last:

Suffix:

Previous Name(s): Social Security Number: * E-mail Address: (This will be the primary communication method) Mailing Address: This is a

Home

PO Box, Street: Business

Daytime Telephone Number: (

City, State, Zip: )

Date of Birth (mm/dd/yyyy): PART 2—LIFE SUPPORT CERTIFICATION

List below and submit proof of current Basic Life Support (BLS) certification for healthcare providers that meets the requirements of Rule III(G)(7), and Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) certification as appropriate. It is the dentist’s responsibility to maintain current BLS and ACLS and/or PALS certification at all times. BLS certification issue or renewal date: —AND—

Expiration date:

ACLS certification issue or renewal date: _______ —AND/OR— PALS certification issue or renewal date:________________________________

Expiration date: Expiration Date: ______________________

* Social Security Number Disclosure: Section 24-34-107(1) of the Colorado Revised Statutes requires that every application by an individual for a license issued pursuant to the authority set forth in title 12, C.R.S., by the Department of Regulatory Agencies, shall require the applicant's social security number. Disclosure of your social security number is mandatory for purposes of establishing, modifying, or enforcing child support under § 14-14-113 and § 26-13-126, C.R.S.; locating an individual who is under an obligation to pay child support as required by § 26-13-107(3)(a)(I)(A), C.R.S.; and reporting to the Health Integrity and Protection Data Bank as required by 45 CFR §§ 61.1 et seq. Failure to provide your social security number for these mandatory purposes will result in the denial of your licensure application. Disclosure of your social security number is voluntary for disclosure to other state regulatory agencies, testing and examination vendors, law enforcement agencies, and other private federations and associations involved in professional regulation for identification purposes only. Your social security number will not be released for any other purpose not provided for by law.

OFFICE USE ONLY Anesthesia Permit—Dentist

DATE APPROVED: ____________________________ Page 1 of 5

DATE ISSUED: _________________________________ 07/2016

APPLICANT NAME:

PART 3—EDUCATION/TRAINING/EXPERIENCE QUALIFICATIONS—MINIMAL SEDATION (Complete only if you are applying for a Minimal Sedation Permit) Check the box (only one) corresponding with the requirements for a Minimal Sedation Permit that you are qualified under, and submit the appropriate documentation. Successful completion of a specialty residency or general practice residency recognized by the Commission on Dental Accreditation (CODA) that includes comprehensive and appropriate training to administer and manage minimal sedation; —OR— Educational criteria for Moderate Sedation Permit or for a Deep Sedation/General Anesthesia Permit; —OR— A minimum of 16 hours of Board-approved coursework completed within the past 5 years that provides training in the administration and induction of minimal sedation techniques and management of complications and emergencies associated with sedation commensurate with the American Dental Association (ADA) 2012 “Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students”. • •

•

The coursework must contain an appropriate combination of didactic instruction and practical skills training. You must submit for Board approval documentation of the training course(s) to include, but not be limited to, a syllabus or course outline of the program and a certificate or other documentation from course sponsors or instructors indicating the number of course hours, content of such courses and date of successful completion. Course content leading to current Basic Life Support (BLS) and/or Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) CANNOT be considered as part of the 16 hours of classroom and clinical instruction.

—OR— Endorsement. The Board may consider qualifications accepted in another state or jurisdiction that resulted in a comparable permit to be issued by that state or jurisdiction which is substantially equivalent to the requirements for a Minimal Sedation Permit in Colorado. • At a minimum, you must demonstrate that you successfully administered minimal sedation in 20 cases within the last 2 years prior to applying, and have had no discipline, morbidity to a patient requiring hospital admission, or patient mortality associated with the administration of sedation.

PART 4—EDUCATION/TRAINING/EXPERIENCE QUALIFICATIONS—MODERATE SEDATION (Complete only if you are applying for a Moderate Sedation Permit) Circle the route (#1 or #2 or #3) corresponding with the requirements for a Moderate Sedation Permit that you are qualified under, check the corresponding box(es), and submit the appropriate documentation. 1.

Education Only Route—Submit documentation of having successfully completed one of the following: A specialty residency or general practice residency recognized by the Commission on Dental Accreditation (CODA) that at a minimum includes comprehensive and appropriate training to administer and manage moderate sedation; • •

60 hours of training in the administration and induction of moderate sedation techniques and management of complications and emergencies associated with sedation commensurate with the American Dental Association (ADA) 2012 “Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students”; AND Sedation cases performed by you on 20 unique patients that were completed as part of the residency where you were both the primary provider of the sedation and direct provider of dental care;

—OR— Educational criteria for a Deep Sedation/General Anesthesia Permit. OR IN THE ALTERNATIVE 2.

Education and Experience Route—Submit proof of successfully completing moderate sedation course(s) and acceptable sedation cases as follows (both boxes must be checked if applying through this route): Education. 60 hours of Board-approved coursework completed within the past 5 years that provides training in the administration and induction of moderate sedation techniques and management of complications and emergencies associated with sedation commensurate with the American Dental Association (ADA) 2012 “Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students”. •

• •

Such coursework must include an appropriate combination of didactic instruction and practical skills training. Coursework must also include documented training in parenteral techniques in order to perform parental sedation once a Moderate Sedation Permit is issued. You must submit for Board approval documentation of the training course(s) to include, but not be limited to, a syllabus or course outline of the program and a certificate or other documentation from course sponsors or instructors indicating the number of course hours, content of such courses and date of successful completion. Course content leading to current Basic Life Support (BLS) and/or Advanced Cardiac Life Support (ACLS) and/or Pediatric Advanced Life Support (PALS) CANNOT be considered as part of the 60 hours of classroom and clinical instruction.

Anesthesia Permit—Dentist

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APPLICANT NAME:

—AND— Experience. Sedation cases performed by you on 20 unique patients that were completed as part of or separate from the Board-approved sedation training course. •

• • • • •

If completed as part of a Board-approved sedation training course, the time spent on cases does not count towards the 60-hour course requirement. If completed separate from the course, then all cases must be completed during the 1 year period immediately after completion of the approved training program. All of the cases must be performed and documented under the on-site instruction and supervision of a person qualified to administer anesthesia at a deep sedation/general anesthesia level. You must be the primary provider of the sedation and directly provide dental care for all required casework. Cases may be performed on live patients or as part of a hands-on high-fidelity simulation center or program; however, a maximum of 5 hands-on high-fidelity simulation cases may be accepted as part of the required 20 sedation cases. All of the cases must meet the documentation and monitoring requirements for moderate sedation set forth in Rule XIV(O) & XIV(P). The cases must meet generally accepted standards for the provision and documentation of moderate sedation in Colorado, regardless of where the cases occurred.

OR IN THE ALTERNATIVE 3.

Endorsement Route—The Board may consider qualifications accepted in another state or jurisdiction that resulted in a comparable permit to be issued by that state or jurisdiction which is substantially equivalent to the requirements for a Moderate Sedation Permit in Colorado. At a minimum, submit proof of the following for consideration: Successfully administered moderate sedation in 20 cases within the last 2 years prior to applying, and have had no discipline, morbidity to a patient requiring hospital admission, or patient mortality associated with the administration of sedation.

PART 5—EDUCATION/TRAINING QUALIFICATIONS—DEEP SEDATION/GENERAL ANESTHESIA (Complete only if you are applying for a Deep Sedation/General Anesthesia Permit) Check the box (only one) corresponding with the requirements for a Deep Sedation/General Anesthesia Permit that you are qualified under, and submit the appropriate documentation. Successful completion of a residency program in general anesthesia that is approved by the Commission on Dental Accreditation (CODA), the Accreditation Council for Graduate Medical Education, or any successor organization to any of the foregoing; —OR—

An acceptable post-doctoral training program (e.g., oral and maxillofacial surgery or dental anesthesiology) that affords comprehensive and appropriate training necessary to administer and manage deep sedation and general anesthesia commensurate with the American Dental Association (ADA) 2012 “Guidelines for Teaching Pain Control and Sedation to Dentists and Dental Students”. PART 6—PEDIATRIC DESIGNATION (Requires that you maintain a current Pediatric Advanced Life Support (PALS) if applying for and maintaining this designation on your anesthesia permit in order to administer to patients under 12 years of age) Check the appropriate box (only one) addressing whether you would like to pursue a Pediatric Designation on your anesthesia permit once issued, and if so, that you have met the applicable requirement, and submit the appropriate documentation. I would like to OPT-OUT of obtaining a Pediatric Designation. If you are applying for a Deep Sedation/General Anesthesia Permit, which automatically makes you eligible to receive a Pediatric Designation, but are not interested in obtaining and maintaining the required PALS certification. —OR— Successful completion of a pediatric residency recognized by the Commission on Dental Accreditation (CODA); —OR— Educational criteria for a Deep Sedation/General Anesthesia Permit; —OR— Completion of the following: • A minimum of 30 hours of education specific to pediatric patients in addition to or as part of the residency pursuant to Rule XIV(J)(1)(a), or the 60 hours of education pursuant to Rule XIV(J)(2)(a); and • 10 pediatric cases in addition to or as part of the residency pursuant to Rule XIV(J)(1)(a), or the 20 cases of experience pursuant to Rule XIV(J)(2)(b). Anesthesia Permit—Dentist

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APPLICANT NAME:

PART 7—SCREENING QUESTIONS Provide the following for each YES response to screening questions 1 through 3: • A personally written explanation; • A copy of the formal complaint/pleading; • The answer to the complaint for malpractice issues; • A copy of the final outcome(s) and/or a report of status if judgment is pending; • Proof of compliance if under criminal probation; • A copy of investigative report/complaint; and • Any further information requested by the Board in a separate communication.

1. Has your license to practice dentistry ever been suspended, revoked, or otherwise disciplined in any state or territory of the United States, or in any foreign country related to an anesthesia/analgesia incident?

YES

NO

2.

YES

NO

YES

NO

Have you ever had any malpractice judgment, malpractice settlement, or governmental/private agency disciplinary action against you or is such an action currently pending against you?

3. Have you ever had any criminal conviction, deferred judgment or plea of nolo contendere entered against you or is there any criminal charge or investigation currently pending against you? This includes, but is not limited to, any judgments/charges related to sales, distribution, possession, manufacture or dispensation of any controlled or illegal substance. Provide the following for each YES response to screening questions 4 through 6: • A personally written explanation. For questions 4 and 5, also give:

• Dates of onset; • Description of treatment; • Name and address of treating physician; and • Your description of the current status of your condition. You may wish to submit a physician’s report of the current status of your condition and any limitations which may affect your ability to safely practice dentistry.

4. Do you now abuse or excessively use, or have you in the last five years abused or excessively used, any habit forming drug, including alcohol, or any controlled substance that has a) resulted in any accusation or discipline for misconduct, unreliability, neglect of work, or failure to meet professional responsibilities; or b) affected your ability to practice as a dentist safely and competently?

YES

NO

5. In the last five years, have you been diagnosed with or treated for a condition that significantly disturbs your cognition, behavior, or motor function, and that may impair your ability to practice as a dentist safely and competently including but not limited to bipolar disorder, severe major depression, schizophrenia or other major psychotic disorder, a neurological illness, or sleep disorder?

YES

NO

6. Are there any other facts concerning your background history, experience, or activities which may have a bearing on your fitness to practice dentistry in Colorado and which should be brought to the attention of the Colorado Dental Board?

YES

NO

Anesthesia Permit—Dentist

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APPLICANT NAME:

ATTESTATION I hereby certify that I have met ALL the requirements for administering anesthesia in the state of Colorado pursuant to section 12-35-140, C.R.S., and Board Rule XIV under the following permit type (check one): Minimal Sedation Permit Moderate Sedation Permit Deep Sedation/General Anesthesia Permit I hereby certify that I have met the requirements to administer anesthesia to patients under 12 years of age in the state of Colorado pursuant to section 12-35-140, C.R.S., and Board Rule XIV (check if applicable): Pediatric Designation I attest that I am in full compliance with all the requirements in Board Rule XIV, including the required office facilities and equipment pursuant to section (M). Furthermore, I attest that an end-tidal carbon dioxide monitor is also included with the required office facilities and equipment if moderate sedation or deep sedation/general anesthesia is being administered in my dental office or if I am administering moderate sedation or deep sedation/general anesthesia in the office of another dentist. I further attest that I will maintain current Basic Life Support (BLS) certification and an Advanced Cardiac Life Support (ACLS) and/or Pediatric Life Support (PALS) certification as long as I am administering anesthesia in the state of Colorado. I further attest that I will complete 17 hours of Board-approved continuing education credits pursuant to Rule XIV(R)(5)(c) during my five-year permit renewal period that are specific to anesthesia or sedation administration, and that they do NOT include time spent maintaining current BLS, ACLS, and/or PALS. I further attest that I will submit to the Colorado Dental Board an anesthesia morbidity/mortality report within 15 days of any anesthesia related incident resulting in morbidity to the patient requiring hospital admission or patient mortality in compliance with Rule XIV(S), if applicable. I state under penalty of perjury in the second degree, as defined in section 18-8-503, C.R.S., that the information contained in this application is true and correct to the best of my knowledge. In accordance with section 18-8501(2)(a)(I), C.R.S., false statements made herein are punishable by law and may constitute a violation of the Dental Practice Act.

Applicant Signature

Anesthesia Permit—Dentist

Date

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