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.
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
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 Applications
Dental Hygiene Nitrous Oxide Permit Application
Local Anesthesia Permit Application
If you have been licensed and permitted in another state to administer local anesthesia in your practice of dental hygiene, and you wish to apply for a permit to administer local anesthesia in Louisiana, please also fill out the affidavit below and submit it with your local anesthesia permit 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.

Affidavit for Opioid Management CE Exemption (DENTISTS ONLY)
Affidavit
Dentists who do not prescribe, dispense, or administer any controlled susbtances are not required to complete the 3 hours of opioid management continuing education. Complete this affidavit in the presence of a notary and mail it to the board office. We will then verify you have not prescribed, dispensed, or administered any controlled substances with the Prescription Monitoring Program.  Should you prescribe, dispense, or administer controlled substances in the future, you will be required to obtain the opioid management CE.

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.

Inspection Form
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
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
Dentist CE Reporting Form
Hygienist CE Reporting Form