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You must complete this form if you are:

  • a dentist and have had any mortality or irreversible morbidity occurring during or within 48 hours following, or otherwise related to, the administration of conscious (moderate) sedation or deep sedation or general anesthesia; or
  • are applying for an anesthesia certificate via endorsement and you have ever had any patients with irreversible morbidity or mortality due to the sedation provided by you.

Complete the entire form. Be sure to sign and date the certification before submitting the completed form along with any other documentation to the Office of the Professions at the address at the end of the form.