Management Branch Office of Licensing

VERIFICATION OF COMPLETION OF TRAINING LOCAL ANESTHESIA

First:

Applicant Name: Last:

Telephone Number: (

Middle:

Suffix:

)

School Name:

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.

—AND— ►

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

Date

F 303.894.7693 www.dora.colorado.gov/professions

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