Forms

The following applications are available in Adobe Acrobat Format (*.pdf). Adobe offers a free plug-in viewer on its website.

Licensee Continuing Education Reporting Forms
(To be completed  by ONLY those licensees who will renew their licenses by December 31, 2013.)
You must complete the appropriate CE reporting form and mail (emailed or faxed forms will NOT be accepted) it to the board office no later than January 31, 2014. You will NOT attach certificates of completion to this form. Please only list the courses you completed during the January 2012-December 2013 license period.
Dental CE Reporting Form
Hygiene CE Reporting Form

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.
If you add a new practice location, it will NOT automatically remove another location. You must submit one form to add a new practice location and a separate form to remove the former practice location.
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.
If you add a new employer to your record, it will NOT automatically remove another employer. You must submit one form to add a new employer and a separate form to remove the former employer.

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.

Controlled Substances Log Form
Sample Controlled Substances Log Form
All dentists are required to maintain an accurate running total of controlled substances in their possession.  Please see the above sample file for your convenience.  This form should be maintained by the dentist.  Do not submit this form to the board.

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