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DEPARTMENT
OF
CONSUMER
AFFAIRS
____________________________________________________________
__________________________________________________
CERTIFICATION OF CONSCIOUS SEDATION TRAINING
Applicant: Complete the upper portion of this form and have your conscious sedation training certified by the
educational institution where you obtained the training. Submit this completed form with your application for
permit.
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 conscious sedation permit to administer or order the administration of conscious sedation in
the dental office in Californi
a. In order to qualify for a permit, applicant is required to provide proof of completion of a
course of stu
dy in conscious sedation. Please check the appropriate box relating to the program applicant completed at
your educatio
nal institution. If assistance is needed in determining educational equivalency to the Guidelines, please
contact the Ameri
can Dental Association.
□ Training
in the administration of conscious sedation consisted of at least 60 hours of instruction; met requirements of
satisfactorily completing at least 20 cases of the administration of conscious sedation for a variety of dental procedures;
and complies in all respects with the requirements of the Guidelines for Teaching the Comprehensive Control of Pain and
Anxiety in Dentistry of the American Dental Association.
□ Training
offered at this educational institution did not satisfy the criteria above.
I hereby ce
rtify that ____________________________________________________satisfactorily completed the above
referenced training at
___________________________________________________. This student was enrolled in a
_____________________________________________________program when obtaining conscious sedation training.
Program
This student obtaine
d this training in __________________________________________.
(Month/Year)
EDUCATIONAL
PROGRAM
SEAL
Signature Date
Printed Name/Title Phone
Form CS-2 Rev. 06/18
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
click to sign
signature
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