Board of Dentistry Forms And Brochures

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Board of Dentistry

Forms And Brochures


Where to Mail Forms	RDH Restorative Functions	Instructor Applications
General Forms	Dental Assistant Certification	Volunteer License Application
Brochures	DA Restorative Functions	Malpractice Claim Report
Dental Applications	Anesthesia Permits
Dental Hygiene Applications	Cert. of Standing Request
Limited Access Permit	Information Requests


Where to Mail Forms

You may print and return completed froms to the following address: Forms with Payment: Oregon Board of Dentistry Unit 23 PO Box 4395 Portland, OR 97208-4395 Forms without Payments: Oregon Board of Dentistry 1600 SW 4th Ave., Ste. 770 Portland, OR 97201 Please direct any questions or problems downloading these forms to: Teresa.Haynes@state.or.us or call us at 971-673-3200 during regular business hours.


General Forms

Complaint Form Dental Continuing Education Log Dental Hygiene Continuing Education Log


Brochures

Confidential Diversion Monitoring Program Volunteer Licensee Program


Dental Applications

Dental Application Packet - Licensure By Examination **This packet is intended for use by those individuals who have taken and passed a clinical examination within the last five years.*** This packet contains all the forms needed to apply for licensure in the State of Oregon. You will need to contact our office to obtain a fingerprint card. To do so, follow the link below. Dental Application Packet - Licensure by Examination Request a Fingerprint Card * Clinical Examination refers to any state or regional exam. Dental Application Packet - Licensure Without Further Examination This packet is intended for use by those individuals who have taken and passed a clinical examination MORE than five years ago. In addition, you must meet the following requirements to qualify for Licensure Without Further Examination (LWOFE) *3500 hours of clinical practice in the five years immediatly preceding application* *40 hours of continuing education in the immediate two years PRIOR to applying* This packet contains all the forms needed to apply for licensure in the State of Oregon. You will need to contact our office to obtain a fingerprint card. To do so, follow the link below. Dental Application Packet - Licensure Without Further Examination Request a Fingerprint Card Individual Dental Application Forms General Information and Instruction Sheet Application Form Biennial Licensure Form (this is NOT a renewal form) Certificate of Licensure Certification of Clinical Practice Class 1 Nitrous Oxide Permit Continuing Education Log DEA Form Diversity Form Privacy Act Notification Application for Certification as a Specialist Fingerprint Cards - Cannot be downloaded from this website. Please contact the Licensing Manager to obtain a finger print card For additional Anesthesia Permit Applications see the 'Anesthesia Permit' section of this page. Not to be used for license renewal. To obtain a renewal application please contact the Board Office.


Dental Hygiene Applications

Dental Hygiene Application Packet - Licensure By Examination *This packet is intended for use by those individuals who have taken and passed a clinical examination within the last five years.** This packet contains all the forms needed to apply for licensure in the state of Oregon. You will need to contact our office to obtain a fingerprint card. To do so, follow the link below. Dental Hygiene Application Packet- Licensure by Examination Request a Fingerprint Card Clinical Examination refers to any state or regional exam. Dental Hygiene Application Packet - Licensure Without Further Examination This packet is intended for use by those individuals who have taken and passed a clinical examination MORE than five years ago. In addition, you must meet the following requirements to qualify for Licensure Without Further Examination (LWOFE). 3500 hours of clinical practice in the five years immediately preceding application* *24 hours of continuing education in the immediate two years PRIOR to applying.* This packet contains all the forms needed for licensure in the State of Oregon. You will need to contact our office to obtain a fingerprint card. To do so, follow the link below. Dental Hygiene Application Packet - Licensure Without Further Examination Request Fingerprint Card Individual Dental Hygiene Application Forms General Information and Instruction Sheet Application Form Biennial Licensure Form (this is NOT a renewal form) Certificate of Licensure Certification of Clinical Practice Class 1 Nitrous Oxide Permit Continuing Education Log Local Anesthesia Endorsment Diversity Form Privacy Act Notification Fingerprint Card - Cannot be downloaded from this website. Please contact the Licensing Manager to obtain a fingerprint card.


Limited Access Permit

Limited Access Permit Application


RDH Restorative Functions

Request for Approval of Restorative Curriculum RDH Restorative Course Curriculum Template Application for Dental Hygiene Restorative Functions Endorsement


Dental Assistant Certification

Certification by Credential Certification by Credential has two pathways through the Oregon Board of Dentistry: Pathway 1: You have a certificate issued by another state that is equivalent to the duties performed in Oregon. Pathway 2: You have performed the duties for the requested certificate for at least 1,000 hours in the past two years in another state. If you do not meet one of these two pathways you will have to contact the Dental Assisting National Board (DANB) at 1-800-367-3262, Ext. 451 Application for Certification by Credential in Expanded Functions (General) Application for Certification by Credential in Expanded Function (Orthodontic) Application for Certification by Credential in Radiologic Proficiency Application for Certification for Anesthesia Dental Assistant


DA Restorative Functions

Request for Approval of Restorative Curriculum DA Restorative Course Curriculum Template Application for Dental Assistant Restorative Functions Certificate


Anesthesia Permits

Anesthesia Rules and Educational Requirements Please review the following information carefully before submitting your anesthesia permit application. Anesthesia Rules Educational Requirements for Anesthesia Permits Anesthesia Permit Applications Class 1 Nitrous Oxide Permit Application Class 2 Conscious Sedation Permit Application Class 3 Deep Sedation & Class 4 General Anesthesia Permit Application


Cert. of Standing Request

Use this form if you are applying for licensure in another state or jurisdiction and need verification of your Oregon dental or dental hygiene license. Certificate of Standing Request


Information Requests

Data Request Order Form Licensee Information Request - this form does not have the official Oregon state seal.


Instructor Applications

Please contact Teresa Haynes at (971)673-3200 for Instructor Applications.


Volunteer License Application

Volunteer License Application


Malpractice Claim Report

Malpractice Claim Report (For Insurance Company Use Only)

Page updated: November 02, 2009

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