Other Applications and Forms

Adverse Occurrence Report

Forms

Report used if a death, or incident requiring emergency medical response, occurs in a dental office or dental clinic during the administration of or recovery from general anesthesia, deep sedation, moderate sedation, or minimal sedation.

Online submission (Once all required fields are completed, a "Click to Sign" button will display at the bottom of your screen.)

Affiliated Practice

Other Applications

Suggested forms and Instructions for reporting an affiliated practice relation between a Dentist and a Dental Hygienist. 
(Please download, complete the document and submit to [email protected] or mail to 1740 W Adams, Suite 2470 Phoenix, AZ 85007)

Restricted Permit to Volunteer, formerly known as: Volunteer Health Services Registration

Other Applications

After some research, it was discovered that the legislative intent for creating the general Volunteer Health Services Registration process was based on the Board's Restricted Permit process. Please be patient as we reconstruct the Restricted Permit application. In the meantime, the Board will continue to receive Volunteer Health Services Registrations to volunteer your dental services at charitable dental clinic or organization. Your application must be submitted by you; no one may submit or attest to its veracity other than you. Your application shall consist of a completed application itself

Continuing Education Extension Request

Forms

Download and save to your computer in order to sign and submit or attach to your Renewal Application, if necessary. If you are submitting apart from your renewal application, please follow the same instructions and once saved, please attach the request to an email submitted to [email protected].

Lists and Labels

Forms

Online Order Form for mailing lists and mailing labels

Registration to Dispense Drugs and Devices

Other Applications

Pursuant to A.A.C. R4-11-1406, a dentist licensed to practice in Arizona may dispense controlled substances, prescription-only drugs and/or prescription-only devices for profit if the dentist completes a registration approved by the Board and submits a copy of their DEA Certificate of Registration. 

Dispense means the delivery by a dentist of a prescription drug or device to a patient, except for samples packaged for individual use by licensed manufacturers or repackagers of drugs, and includes the prescribing, administering, packaging, labeling and security necessary to prepare and