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.

Complaints

• Complaint Form and Medical Release Form.pdf
  

Dentists

General

• Infection Control Inspection Checklist
• Verification of Licensure or Registration Form
• Duplicate License or Registration Request Form
• Notification of Intent to Contract for Continuation of Practice for Incapacitated or Deceased Dentist

Licensure

• Application for Dental Licensure
• Statement Regarding Student Licensure Limitations
• Statement Regarding Faculty Licensure Limitations
  

Retirement/Reinstatement

• Retirement of License Form
• Application to Reinstate a Dental License
  
• Affidavit for Active Practice as a Dentist
  

Anesthesia Permits

• Application for Sedation or Anesthesia Permit
• Application for Sedation or Anesthesia Facility Certificate
• Sedation or Anesthesia Permit Location Notification Form

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 appointment. 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
• Moderate Parenteral and Moderate Pediatric Sedation Facility Checklist
• Moderate Enteral and Minimal Pediatric Sedation Facility Checklist

Specialty Licensure

• Application for Specialty Licensure

Charitable Licensure

• Application for Charitable Dental Licensure

Dental Hygienists

General

• Delegated Duty List
• Verification of Licensure or Registration Form
• Duplicate License or Registration Request Form

Licensure

• Application for Dental Hygiene Licensure

Retirement/Reinstatement

• Retirement of License Form
• Application to Reinstate a Dental Hygiene License

Dental Hygiene Registration Applications

• Dental Hygiene Local Anesthesia Registration Application
• General Supervision Application
• Application for Intravenous Access Line Registration
• Application for Laser Debridement Registration
• Public Health Registered Dental Hygienist Application

Charitable Licensure

• Application for Charitable Dental Hygiene Licensure

Registered Dental Assistants

• Radiography Technique Training

Dental Lab Registration

• ​Application for Registration of Dental Laboratories
• Renewal Application for Registration of Dental Laboratories

Services

• Advisory Opinion Request Form
•  Kentucky Dentist List Order Form
•  Kentucky Hygienist List Order Form