Other Applications and Forms
Adverse Occurrence Report
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
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 contact DANB directly at 800.367.3262 or through their website at danb.org/contact-us.
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 Entity Registration Initial & Renewal Application
Please read these application instructions and information.
Business entity registration is required by any dental business entity, not exclusively owned by a dentist(s), who are licensed in Arizona.
Online submission (Once all required fields are completed, a "Click to Sign" button will display at the bottom of your screen.)
Dental Assistant Coronal Polishing Certification
Please contact DANB directly at 800.367.3262 or through their website at danb.org/contact-us.
Dentist and Dental Hygienist Restricted Permit
Lists and Labels
Online Order Form for mailing lists and mailing labels
Malpractice Addendum
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.
Registration to Dispense Drugs and Devices
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