Forms

Following are links to all of the forms and checklists available on our website. For further information, please use the links in the left hand navigation or contact the Board office.

You can search this page by typing CTRL+F on your keyboard and entering a keyword (for example, searching for "disk" will help you find the Disk Order Form).

• Complaint Form and Medical Records Release Form 

General

• Infection Control Inspection Checklist [PDF - 266k]
• Delegated Duty List [PDF - 328k]
• Verification of Licensure or Registration Form [PDF - 270k]
• Duplicate License or Registration Request Form [PDF - 272k]
• Public Comments on Pending Regulations [PDF - 236K]

Licensure

• Application for Dental Licensure [PDF - 299k]
• Statement Regarding Student Licensure Limitations [PDF - 234k]
• Statement Regarding Faculty Licensure Limitations [PDF - 234k]
• Affidavit for Active Practice as a Dentist [PDF - 60k]

Retirement/Reinstatement

• Retirement of License Form [PDF - 250k]
• Application to Reinstate a Dental License [PDF - 294k]

Anesthesia Permits

• Application for Sedation or Anesthesia Permit [PDF - 343k]
• Application for Sedation or Anesthesia Facility Certificate [PDF - 339K] 
• Sedation or Anesthesia Permit Location Notification Form [PDF - 317K]

Anesthesia Facilities Checklists

It is extremely important that inspection appointments are NOT CANCELLED or rescheduled!
Please insure you have EVERY item on the checklist at your office BEFORE you schedule an appoinment.
Please check your calendar carefully before you confirm the date and time with the inspector.

Do not schedule patients for sedation
until your facility has passed inspection.

• Deep Sedation and General Anesthesia Facility Checklist [PDF - 367k]  
• Moderate Parenteral and Moderate Pediatric Sedation Facility Checklist [PDF - 366k]  
• Moderate Enteral and Minimal Pediatric Sedation Facility Checklist [PDF - 373k]  

Specialty Licensure

• Application for Specialty Licensure [PDF - 278k]

Charitable Licensure

• Application for Charitable Dental Licensure [PDF - 297k]

General

• Delegated Duty List [PDF - 328k]
• Verification of Licensure or Registration Form [PDF - 270k]
• Duplicate License or Registration Request Form [PDF - 272k]

Licensure

• Application for Dental Hygiene Licensure [PDF - 306k]

Retirement/Reinstatement

• Retirement of License Form [PDF - 250k]
• Application to Reinstate a Dental Hygiene License [PDF - 294k]

Dental Hygiene Registration Applications

• Dental Hygiene Local Anesthesia Registration Application [PDF - 320k]
• General Supervision Registration Application [PDF - 333k]
• Application for Intravenous Access Line Registration [PDF - 342k]
• Application for Laser Debridement Registration [PDF - 322k]

Charitable Licensure

• Application for Charitable Dental Hygiene Licensure [PDF - 299k]

• Delegated Duty List [PDF - 328k]
• Radiography Technique Training [PDF-226K]

• Kentucky Active Dentist List Order Form
• Kentucky Active Dental Hygienists List Order Form