Application Forms

The following forms may be printed and attached with your application for license, permit, registration or qualification.  If the application will be completed online, you may scan/photograph and attach the completed forms prior to submitting the application.  If you have already submitted an application, you may email or fax the completed forms.  

Please note: The original copy of the Certification of Education should be forwarded to the Board office to complete your application.

National Practitioner Data Bank (NPDB)

Applicants for a dental license, dental hygiene license or faculty permit must submit the results of a self-query of the National Practitioner Data Bank.  To submit a request to the NPDB for a self query, please visit the NPDB's website.  Upon receipt of the results, please email or fax a copy of the results to the Board office.  You are not required to forward an original copy of the results to the Board.

Dental Assistants
Dental Assistant Trainee Signature of Applicant/Statement of Employer
RDA/QDA Application Forms

Affidavit of Employment (Required if training was completed as a dental assistant trainee.)

Certification of Education (For graduates of an ADA-accredited dental assisting program.)

XDA/QDA Radiography Qualification
(For Iowa nurses applying for an XDA, or an RDA applying for a QDA.)

 Certification of Dental Radiography Training

Dental Hygienists
RDH License Application Forms

Authorization for Release

Certification of Education

Certification of License*
*Request a written certification of all licenses that have been issued to you, including states where you may not have practiced or the license is no longer current.
Local Anesthesia Application Forms

Certification of Local Anesthesia Training

Certification of Local Anesthesia Administration

Dentists
DDS License Application Forms

Authorization for Release

Certification of Education

Certification of License*
*Request a written certification of all licenses that have been issued to you, including states where you may not have practiced or the license is no longer current.
Moderate Sedation or General Anesthesia Application Forms

Certification of Moderate Sedation Training

Verification of Postgraduate Residency Program (General Anesthesia)

Faculty/Residents
The following forms need to be submitted with an application for faculty permit or resident license.  The forms must be completed by the University of Iowa College of Dentistry or other ADA-accredited program in Iowa where the applicant is employed as a faculty member or enrolled as a resident.  
Faculty Certification Faculty Certification
Resident Certification Resident Certification

Please submit the completed forms to:

Iowa Dental Board
400 SW 8th St. Suite D
Des Moines, IA 50309
Email: IDB@iowa.gov
Fax:    515-281-7969

Printed from the website on May 31, 2020 at 8:24pm.