LARA/BPL-DENTANESTH (10/16)
The Department of Licensing and Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color, marital status,
disability, or political beliefs. If you need assistance with reading, writing, hearing, etc., under the Americans with Disabilities Act, you may make your needs known to this agency.
Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
(517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
VERIFICATION OF LOCAL ANESTHESIA ADMINISTRATION TRAINING
Authority: 1978 PA 368
This certification form must be submitted directly to this office by the school where the didactic and clinical administration of
local anesthesia training was completed.
Section of Form to be Completed by Applicant:
Applicant’s Name (First, Middle, Last)
Date of Birth
Name of School
Date of Completion
Applicant’s Signature
Date
Remainder of Form to be Completed by School:
CERTIFICATION AND SIGNATURE
I certify the applicant named above has completed a minimum of 15 hours of didactic instruction and 14 hours of clinical
experience in the local anesthesia administration where the content of the course included theory of pain control,
selection of pain control modalities, anatomy, neurophysiology, pharmacology of local anesthetics, pharmacology of
vasoconstrictors, psychological aspects of pain control, systemic complications, techniques of maxillary anesthesia,
techniques of mandibular anesthesia, infection control, and local anesthesia medical emergencies.
___________________________
_____________________ _______________________________________
Authorized Signature Date
___________________________
_____________________
Print/Type Name and Title (Seal)
click to sign
signature
click to edit
![]()
