Dental Board

Application Forms

• Application for Licensure - Dental Hygienist
• Application for Licensure - Dental Specialist
• Application for Licensure - Dentist
• Dental Hygiene Permits
• Verification of Licensure
• Verification of Specialty Licensure
• Application for a Permit to Assist the Administration of and Monitor Nitrous Oxide Analgesia

Use these forms for a permit to administer enteral (oral), and/or parenteral (IV) and/or deep sedation/general anesthesia.

• App. for enteral conscious sedation permit
• App. for enteral conscious sedation site certificate
• Verification of Completion of a Missouri Dental Board Approved Course form
• App. for parenteral conscious sedation permit
• App. for parenteral conscious sedation site certificate
• Verification of parenteral conscious sedation requirements
• Affidavit of written protocols for sedation of dental patients
• App. for deep sedation/general anesthesia permit
• App. for deep sedation/general anesthesia site certificate
• Verification of deep sedation/general anesthesia requirements

Use this form to apply for a permit or registration as a non-for-profit entity providing dental services in the State of Missouri pursuant to the provisions of Chapter 332 of the Revised Statutes of Missouri. This goes into effect August 28, 2004.

• Application for permit/registration to provide dental services

All non-for-profit entities who register as a Federally Qualified Health Center (FQHC) must have each licensee complete the certification form.

• Certification of licensee employed by, or contracting with, an FQHC

Use this form to comply with the State regulation requiring the report of a patient injury or death to the Board.

• Patient Injury or Death Reporting Form