CERTIFICATION OF ORAL CONSCIOUS SEDATION FOR MINORS TRAINING
Applicant: Complete the top of this form and have your oral conscious sedation training by the educational institution where you
obtained the training. Submit this completed form with your application for the certificate.
Applicant Name
California Dental License Number
Name of School attended and dates
EDUCATIONAL INSTITUTION: Complete This Portion Of Form
This dentist is applying for a certificate to administer or order the administration of oral conscious sedation on an
outpatient basis to minor patients in California. One means to qualify for a certificate is to provide proof of completion
of a board approved educational program on oral medications and sedation.
Training offered at this educational institution did not satisfy the criteria outlined in California Code of
Regulations Section 1044.3.
Signature Date
Printed Name & Title Telephone No.
Training in oral medications and sedation consisted of satisfactory completion of at least 25 hours of instruction
including a clinical component consisting of an adequate number of cases to demonstrate personal competency
in oral conscious sedation of a minor patient. The course included the areas outlined in California Code of
Regulations Section 1044.3 incorporated herein by reference.
I hereby certify that satisfactorily completed
(Name)
referenced instruction at . Participant was enrolled
in a program when obtaining training in oral
medications and sedation.
Dates of training
Signature Date
Printed Name Title Telephone Number
Seal of Educational
Institution
BUSINESS, CONSUMER SERVICES, AND HOUSING AGENCY • GAVIN NEWSOM, GOVERNOR
DENTAL BOARD OF CALIFORNIA
2005 Evergreen St., Suite 1550, Sacramento, CA 95815
P (916) 263-2300 | F (916) 263-2140 | www.dbc.ca.gov
. I
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signature
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