Other Applications and Forms
Adverse Occurrence Report
Form used to report any death or incident causing a patient temporary or permanent physical or mental injury occurring in a dental outpatient facility.
Affiliated Practice
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)
Dental Assistant EFDA Certification
(Please download, complete the document and submit to [email protected] or mail to 1740 W Adams, Suite 2470 Phoenix, AZ 85007)
Dentist and Dental Hygienist Volunteer Health Services Registration
(Please download, complete the document and submit to [email protected] or mail to 1740 W Adams, Suite 2470 Phoenix, AZ 85007)
Business Registration
Required by any dental business entity, not exclusively owned by a dental licensee, which provides dental services.
(Please download, complete the document and submit to [email protected] or mail to 1740 W Adams, Suite 2470 Phoenix, AZ 85007)
Dental Assistant Coronal Polishing Certification
Dentist and Dental Hygienist Restricted Permit
Dispensing For Profit
Registration and application and instructions for dentists who dispense drugs or devices for profit.
Lists and Labels
Online Order Form for mailing lists and mailing labels
Mobile Dental Unit & Portable Dental Unit Permit
Beginning January 1, 2012 required for mobile dental facilities and providers, programs or entities using portable dental units.