(If foreign dental school graduate are you certified by the Educational Council for Dental School Graduates?
Do or will you practice as :
Are you employed full time by the Federal Government or currently engaged in military service?
Do you own or plan to own/operate a training facility for dental assistants or auxiliaries?
Has any hospital ever restricted or revoked privileges or put you under probation?
Have you ever been denied a dental license or been denied certification by a specialty board?
Have you had any hearings or investigations before the Department of Occupational and Professional Licensing in Utah or before the Dental Board of any other State?
Has your dental license ever been suspended, revoked, or voluntarily surrendered, or has probation on your license ever been imposed in any state where you have been licensed?
Has your state license to prescribe or DEA Number ever been suspended, revoked, or voluntarily surrendered?
Have you ever been convicted or pled guilty to a felony crime?
Has any dental malpractice claim ever been made against you?
Has any malpractice insurance carrier ever cancelled or refused coverage?
Are you now or have you ever voluntarily or involuntarily participated in a diversion program or rehabilitation program for drug or alcohol abuse?
Have you been investigated by a state association or component society peer review committee?
Have there been any serious or life-threatening incidents in your practice?
Do you plan on having your dental hygienist(s) give local anesthetics?
If yes, does he/she have her own coverage?
Are you currently CPR Certified?
Up to date on required CE Hours?
Have you established emergency procedures, personnel and equipment to cope with patient emergencies, such as cardiac arrest, anaphylactic shock, etc.?
Do you keep a record of pertinent patient phone calls regarding treatment?
Do you document and verify all patient referrals to specialists?
Do you plan to have patients sign a Consent to Proceed plus detailed Consent forms for specific procedures? PIE will furnish example forms.
Are you affiliated with any Dental School Faculty?
If you use Valium or Vistaril or nitrous oxide only for sedation you do not need to fill out this form
YOU MUST CARRY PIE CLASS II COVERAGE IF YOU PROVIDE ENTERAL OR PARENTERAL SEDATION
Current emergency drugs
Positive pressure oxygen
Do all patients who undergo oral conscious sedation sign a written informed consent form specific for oral sedation that has been reviewed and approved by PIE?
Do you have patients complete a health history form within one week of a scheduled procedure that expresses no contraindications to the use of oral sedative agents?
Do you keep a supply of reversal drugs (e.g. Romazicon) available?
Do you log vital signs at specific intervals during the procedure?
Do you limit the oral sedation technique to patients over 18 and under 60 years old, or have you taken an advanced course on sedation for children and elderly pts?
Furnish copy of Course Attendance Certificate.
PIE requires you to take a refresher course every three years
Do all patients who undergo parenteral sedation sign an informed consent form specific for parenteral sedation that has been reviewed and approved by PIE?
Do you utilize a third person (besides you and your dental assistant) whose sole duty is to monitor the patient and record pertinent data during the procedure?
Please answer the following questions if you were graduated from dental school within five years of submitting this application:
Did you ever fail any portion of your National Board Examinations?
Did you fail any course, clinical or didactic, during dental school?
Did you have to repeat any of the above courses more than once?
Did you graduate on time, i.e. on the date that your dental school class was scheduled to graduate?
Did you pass the above state or regional examinations on your first attempt?
Did you ever fail a state or Regional Licensing Board Examination?
WHEREAS, the undersigned is a resident of the State of Utah and is licensed to practice dentistry in the State of Utah;
WHEREAS, the undersigned desires to enter into membership among other subscribers of a mutual insurance company providing indemnity against professional liability, said mutual insurance Company shall be known as Professional Insurance Exchange Mutual, Inc. (PIE)
NOW THEREFORE, the undersigned agrees with PIE and the other subscribers
IT IS FURTHER AGREED that the subscribers' Board of Directors shall consist of nine members elected at the annual meeting of subscribers by the subscribers exercising one vote each. Board members shall be elected for terms of three years each. Terms shall be staggered such that three positions are due for election each year. Not less than eight such Board members shall be subscribers or members of PIE. The Subscribers' Board of Directors shall supervise the finances of Professional Insurance Exchange Mutual, Inc. and supervise its operations to assure conformity with this Agreement and the Bylaws of the Company, procure examinations or audits of the accounts and records of Professional Insurance Exchange Mutual, Inc. and shall have such additional powers and functions as may be conferred from time to time by majority vote of the subscribers.
Please type or print your name and residence address: