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
***IF YOU REPORT YOUR CE THROUGH CE BROKER, YOU DO NOT NEED TO COMPLETE THE CE REPORTING FORM***
(To be completed by ONLY those licensees who will renew their licenses by December 31, 2016.)
You must either report your continuing education through CE Broker by January 31, 2017, or through the following paper CE reporting form and mail (emailed or faxed forms will NOT be accepted) it to the board office no later than January 31, 2017. You will NOT attach certificates of completion to this form. Please only list the courses you completed during the January 2015-December 2016 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
Effective January 20, 2016, qualified third party anesthesia providers may administer sedation and anethesia in any dental office at which there exists an office permit for that level of anesthesia or higher. Qualified third parties are Louisiana licensed physicians specializing in anesthesiology, Louisiana licensed certified registered nurse anesthetists, and Louisiana licensed dentists possessing a personal permit.
Moderate Sedation Application
General Anesthesia Application
Office permits for any level of anesthesia other than nitrous oxide require an office inspection. Please use the following inspection sheet as a checklist to ensure you have the appropriate equipment and information available for the inspector.
Anesthesia Inspection Sheet
Dental Hygiene Anesthesia Permit
Hygiene Nitrous Oxide Permit Application
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
Mobile or Portable Dental Office Permit
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.
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.
Dental Office CDC Inspection Information
Each private dental office in Louisiana is subject to being inspected by the Louisiana State Board of Dentistry for compliance with CDC guidelines for infection control. Each office is generally inspected once every three years. The forms below contain information regarding these inspections.
Sample Inspection Notice
This is an example of the notice a dentist should receive approximately one week prior to the scheduled CDC inspection.
The inspector will use this form when inspecting the dentist's office. Please use the inspection sheet as a checklist so that the appropriate equipment and documenation is available for the inspector.
HBV Vaccine Declination
Dentists are required to offer certain personnel the Hepatitis B vaccine at no charge. The dentist should maintain information regarding the staff's HBV vaccinations. If any employee refuses the HBV vaccine, a declination statement should be maintained in the dentist's office. The declination form above is an example of this statement.
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
Application for Expungement of First
Time Advertising Violations
DEA 224 New Application or DEA -
106 Theft or Loss Report
Miscellaneous Publications and Forms
Dental Information Sheet (newly licensed dentists only)
Hygiene Information Sheet (newly licensed hygienists only)
Radiology Course List