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)

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