Other Applications and Forms

Adverse Occurrence Report

Forms

Please file this report 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, a completed Statement of Citizenship, including supporting documentation, a copy of a Self-Query from the National Practitioner Databank and all verification(s) of all current and past licenses.

Business Entity Registration Change Form

Other Applications

Pursuant to A.R.S. § 32-1213(E), business entities are required to notify the Board, in writing, within 30 days, any change to the business entity's name, address, or telephone number; any change in the officers/directors; any change of dentists authorized to provide dental services; and/or the name of the custodian of records.

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

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

Mobile Dental Unit & Portable Dental Unit Permit

Other Applications

A Mobile Dental Unit & Portable Dental Permit is required if you operate a facility in which your dentistry is being practiced in a mobile facility that is routinely towed, moved or transported from one location or another, OR if you practice dentistry in a non-facility in which dental equipment being used is transported on a temporary basis at an out-of-office location.

A person who holds this type of permit is someone who is authorized to offer dental services in Arizona or a nonprofit organization, school district or school or institution of higher education. 

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