Forms
The following applications are available in
Adobe Acrobat Format
(*.pdf). Adobe offers a free plug-in viewer on its website.
Licensee Change of Information Forms
Each of the change forms may contain information for one licensee and one address only. To submit multiple changes, you must submit separate forms.
Change of Mailing or Home Address
All dentists and hygienists are required to notify the board within 30 days of their change of mailing address.
Change of Practice Location (dentists only)
All Louisiana dentists are required to notify the board of any changes of practice location within 30 days of the date of the change.
Notifying the board of your change of practice location will NOT change your official mailing address on file with the board. To change your official mailing address, use the “Change of Mailing or Home Address” form above.
Change of Employer (hygienists only)
All Louisiana hygienists are required to notify the board of any changes in their employing dentist within 30 days of the date of the change.
Notifying the board of your change of employer and practice location will NOT change your official mailing address on file with the board. To change your official mailing address, use the “Change of Mailing or Home Address” form above.
Dental Anesthesia Permit Applications
Nitrous
Oxide Application
Enteral
Moderate Sedation Application
Parenteral Moderate
Sedation Application
General Anesthesia Application
Third Party Anesthesia Provider Application (CRNAs, medical doctors, etc., administering anesthesia to dental patients)
Dental Hygiene Anesthesia Permit
Applications
Dental
Hygiene Nitrous Oxide Permit Application
Local
Anesthesia Permit Application
If you have taken a local anesthesia course
outside Louisiana, and wish to apply for a local anesthesia permit, please
also fill out the affidavit below and submit it with your local anesthesia
application.
Local
Anesthesia Affidavit
Mobile or Portable Dental Office Permit
Applications
Mobile Dental
Office Permit Application
A mobile office is a self-contained movable facility such as an RV.
A mobile dental office permit will only
be issued to a Louisiana licensed dentist.
Portable
Dental Office Permit Application
A portable office consists of portable dental equipment which is set up on site.
A portable dental office permit will only be
issued to a Louisiana licensed dentist.
Expanded Duty Dental Assistants
EDDA
Application
Application for Expungement of First
Time Advertising Violations
Expungement
Application
DEA 224 New Application or DEA -
106 Theft or Loss Report
DEA
Forms
Miscellaneous Publications and Forms
Dental Information Sheet (newly licensed dentists only)
Hygiene Information Sheet (newly licensed hygienists only)
HIV/HBV/HCV
Reporting Form
Approved
Radiology Course List
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