LARA/BPL-DENTOXIDE (10/18)
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Bureau of Professional Licensing
PO Box 30670 ● Lansing, MI 48909
(517) 335-0918
www.michigan.gov/bpl
BPLHelp@michigan.gov
VERIFICATION OF NITROUS OXIDE ANALGESIA TRAINING
Authority: 1978 PA 368
This certification form must be submitted directly to this office by the school where the didactic and clinical use of nitrous
oxide analgesia training was completed.
Section of Form to be Completed by Applicant:
Applicant’s Name (First, Middle, Last)
Date of Birth
Name of School
Applicant’s Signature
Remainder of Form to be Completed by School:
CERTIFICATION AND SIGNATURE
I certify the applicant named above has completed instruction as follows:
A cour
se in the assisting and monitoring of the administration of nitrous oxide analgesia containing a minimum of 4 hours
of didactic instruction and 4 hours of clinical experience. The course included content in all of the following: nitrous oxide
analgesia medical emergencies techniques, pharmacology of nitrous oxide, nitrous oxide techniques, and a course in
selection of pain control modalities (if available).
_____________________________________________
___ _______________________________________
Authorized Signature Date
________________________________________________
Print/Type Name and Title (Seal)
