Management Branch Office of Licensing
VERIFICATION OF COMPLETION OF TRAINING LOCAL ANESTHESIA
Applicant Name: Last:
Telephone Number: (
Date of training completion:
The above-named person, who is applying for a permit to administer local anesthetic or local anesthetic reversal agents under the indirect supervision of a dentist as a dental hygienist, has met the requirements of Rule XIV(H) by successfully completing the following courses conducted by a school accredited by the Commission on Dental Accreditation (CODA): ►
Twelve (12) hours of didactic training, including but not limited to: • Anatomy; • Pharmacology; • Techniques; • Physiology; and • Medical Emergencies.
Twelve (12) hours of clinical training that includes the administration of at least six (6) infiltration and six (6) block injections.
I hereby declare under penalty of perjury under the laws of the state of Colorado that the above statements are true and correct.
______ Signature of Dean/Registrar/Director
1560 Broadway, Suite 1350, Denver, CO 80202 P 303.894.7800
F 303.894.7693 www.dora.colorado.gov/professions