STATE OF IOWA IOWA DENTAL BOARD

TERRY E. BRANSTAD, GOVERNOR JILL STUECKER KIM REYNOLDS, LT. GOVERNOR EXECUTIVE DIRECTOR

ANESTHESIA CREDENTIALS COMMITTEE AGENDA MAY 25, 2017 12:00 P.M.

Location: The public can participate in the public session of the teleconference by speakerphone the Board’s office, 400 SW 8th St., Suite D, Des Moines, Iowa. The public can also participate by telephone using the call-in information below:

1. Dial the following number to the conference call: 1-866-685-1580 2. When promoted, enter the following conference code: 0009990326#

Members: Steven Fuller, D.D.S. Chair; Steven Clark, D.D.S.; John Frank, D.D.S.; Douglas Horton, D.D.S.; Gary Roth, D.D.S.; Kurt Westlund, D.D.S.; Jonathan DeJong, D.D.S. (alternate)

I. CALL MEETING TO ORDER – ROLL CALL

II. COMMITTEE MINUTES a. April 6, 2017 – Teleconference

III. APPLICATION FOR GENERAL ANESTHESIA PERMIT a. Kevin Gams, D.D.S.

IV. APPLICATION FOR MODERATE SEDATION PERMIT a. Kristen Berning, D.D.S. b. Alexia Oetken, D.D.S.

V. OPPORTUNITY FOR PUBLIC COMMENT

VI. ADJOURN

If you require the assistance of auxiliary aids or services to participate in or attend the meeting because of a disability, please call the Board office at 515/281-5157.

Please Note: At the discretion of the committee chair, agenda items may be taken out of order to accommodate scheduling requests of committee members, presenters or attendees or to facilitate meeting efficiency.

400 SW 8th STREET, SUITE D, DES MOINES, IA 50309-4687 PHONE:515-281-5157 FAX:515-281-7969 http://www.dentalboard.iowa.gov STATE OF IOWA IOWA DENTAL BOARD

TERRY E. BRANSTAD, GOVERNOR JILL STUECKER KIM REYNOLDS, LT. GOVERNOR EXECUTIVE DIRECTOR

ANESTHESIA CREDENTIALS COMMITTEE

MINUTES April 6, 2017 Conference Room 400 S.W. 8th St., Suite D Des Moines, Iowa

Committee Members April 6, 2017 Steven Fuller, D.D.S. Present Steven Clark, D.D.S. Present John Frank, D.D.S. Present Douglas Horton, D.D.S. Present Gary Roth, D.D.S. Present Kaaren Vargas, D.D.S. Absent Kurt Westlund, D.D.S. Present Jonathan DeJong, D.D.S. (alternate) Present Staff Member Christel Braness, Phil McCollum, David Schultz

I. CALL MEETING TO ORDER – APRIL 6, 2017

Ms. Braness called the meeting of the Anesthesia Credentials Committee to order at 12:05 p.m. on Thursday, April 6, 2017. This meeting was held by electronic means in compliance with Iowa Code section 21.8. The purpose of the meeting was to review committee minutes, applications for sedation permits, and other committee business. It was impractical for the committee to meet in person with such a short agenda.

Roll Call: Member Clark DeJong Frank Fuller Horton Roth Westlund Vargas Present x x x x x Absent x x x A quorum was establiDRAFTshed with five (5) members present.

II. COMMITTEE MEETING MINUTES

. January 19, 2017 – Meeting

400 SW 8th STREET, SUITE D, DES MOINES, IA 50309-4687 PHONE:515-281-5157 FAX:515-281-7969 http://www.dentalboard.iowa.gov  MOVED by ROTH, SECONDED by FULLER, to APPROVE the minutes as submitted. Motion APPROVED unanimously.

III. APPLICATION FOR GENERAL ANESTHESIA PERMIT

. Michael Morio, D.D.S.

Ms. Braness provided an overview of Dr. Morio’s application. Dr. Morio is joining an existing practice upon completion of his residency program. The facilities have been previously inspected.

 MOVED by ROTH, SECONDED by DEJONG, to APPROVE the application as submitted upon completion of his residency program.

 Dr. Clark and Dr. Westlund joined the call.

 Vote taken. Motion APPROVED unanimously. Dr. Frank abstained from the discussion and vote as Dr. Morio will be joining his practice.

IV. APPLICATIONS FOR MODERATE SEDATION PERMIT

Ms. Braness reported that the Board had not received any new moderate sedation applications to date.

V. OTHER BUSINESS

. Discussion – ADA Updates for Sedation and General Anesthesia by Dentists

Ms. Braness reported that the ADA sent out further correspondence clarifying the recent recommendations. Rumors suggested that there was a recommendation to allow practitioners offer sedation to grandfather in to current requirements. The correspondence clarified that the ADA made no such recommendation.

Dr. Frank questioned implementation of the new recommendations in Iowa. Ms. Braness stated that until new rules were approved by the Board and made effective, that the current regulations would continue to apply.

. Discussion – Administration, Monitoring and Management of Sedation of Pediatric Patients

Ms. Braness reported that this item was added to the agenda to discuss the matter of pediatric sedation, and whatDRAFT additional guidelines, if any, should be implemented to safeguard against complications that may arise during the sedation of a pediatric patient.

Dr. Westlund asked if the ADA voted on the recommendations from the Academy of Pediatric Dentistry (APPD); and if no, whether they intended to vote on the implementation of those recommendations. Dr. Frank stated that the way he interpreted the ADA recommendations was

Anesthesia Credentials Committee – Subject to ACC Approval April 6, 2017 (Draft: 4/6/2017) 2

that the ADA would refer to the standards established by the American Academy of Pediatrics (AAP) and the AAPD.

Dr. Westlund recommended that staff confirm what the ADA’s position was on the AAP’s and the AAPD’s recommendations for the sedation of pediatric patients. Ms. Braness stated that she would follow up on this item, and that the discussion could be tabled and brought back at a later meeting.

. Discussion – Emergencies and Airway Management

Ms. Braness provided an overview of the discussion. Dr. Frank reported that he was at the recent meeting of the American Dental Society of Anesthesiology (ADSA). Dr. Frank discussed this issue with some of the experts there. The experts that he spoke with did not believe that succinylcholine would be necessary in the use of moderate sedation. Dr. Frank’s concern was that an unintended transition to a deeper level of sedation can occur, particularly with pediatric patients. Laryngospasms are not always managed with positive pressure, and may require treatment with medication. Dr. Frank believed that providers should know how to use succinylcholine.

Dr. Horton stated that he would be attending the upcoming meeting of the ADSA. The use of succinylcholine is listed on the agenda for that meeting. Given that information, Mr. McCollum recommended tabling this discussion until information could be obtained.

. Information – Open Records Request for Sedation Requirements and Adverse Occurrences

Ms. Braness provided the committee with an overview of the open records request. Dr. Roth asked that the committee be provided a copy of the response for their information.

VI. ADMINISTRATIVE RULES

. Recommendation – (Draft) Notice of Intended Action: Iowa Administrative Code 650— Chapter 29, “Sedation and Nitrous Oxide Inhalation Analgesia”

Ms. Braness reported that some of the language in the draft had been updated to more closely match the language used by the ADA in their recommendations.

Due to other rulemaking priorities, these proposals will likely not be submitted to the Board as a Notice of Intended Action until the July 2017 quarterly meeting.

Mr. McCollum touched on the addition of a definition for “hospitalization.” Since the office gets questions about this, Mr. McCollum wanted to be sure that the committee was satisfied with the definition. The committeeDRAFT members did not have any comments.

Dr. Clark inquired about the additional language related to ACLS/PALS certification. Dr. Clark stated that there were some questions about what the language meant. Ms. Braness stated that the language intended to require a practitioner to have to demonstrate competency in these measures as a part of their certification. Portions of the certification may be completed online provided there

Anesthesia Credentials Committee – Subject to ACC Approval April 6, 2017 (Draft: 4/6/2017) 3

is an in-person component with an ACLS/PALS instructor to ensure competency; however, online- only courses would be prohibited.

VII. OPPORTUNITY FOR PUBLIC COMMENT

There weren’t any comments received.

VIII. ADJOURN

 MOVED by WESTLUND, SECONDED by CLARK, to ADJOURN. Motion APPROVED unanimously.

The Anesthesia Credentials Committee adjourned its meeting at 12:27 p.m.

NEXT MEETING OF THE COMMITTEE

The next meeting of the Anesthesia Credentials Committee is scheduled for May 25, 2017. The meeting will be held at the Board office and by teleconference.

These minutes are respectfully submitted by Christel Braness, Program Planner 2, Iowa Dental Board.

DRAFT

Anesthesia Credentials Committee – Subject to ACC Approval April 6, 2017 (Draft: 4/6/2017) 4

ffiH-:#ffilVEm IOWA DENTAL BOARD trPi{ $ ? 2nX7 400 S.W etn Street, Suite D, Des illolnes, lowa S030$46EI Phone (Sl5l 281-5157 Fax (515) 28{.7gtg

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APPLICATION FOR DEEP SEDATION'GENERAL AT{ESTHESIA PERTiIT

$ECT]ON 1 * APPUCANT INFORMATION lll3filaton3 - PlBasa Eld iha sccorlpsn ng InEfrudims pdor to complsdng this lbErl A,r !r sadl qu6s[on, f not epdicabL, m.tk ,tUA., Full Leg-al Nanre: {[.ast, Flrst, Middle, Sufiix] (irqwrs l(e".: tt^rr^ t. S Othff Namee Used: (e.9. Maiden| "r Honre E-mail: Work E-mail; N tk Kgvl vrecr ra,tc @ arfrlr-i I . fo..-. Keu tn . eq,r^S(?{tl,}rnrC. ("1,^ Stah: Zip: v Home Phone: i$Hd't:ith* 6,*6 er rrxocy rt'{ ts "to'f.{"iI -[or te..^ TX ? I ta$?q*q66l) Ucense Number: .. Issue Date: Explration Date: IyPe of Pracucer +Pt,r'c* Lb'a+*#HJ N lrt [tr# N/4 $ECTION 2 * LOCATION($I IN IOWAWHERE SEOAflON SERV|CTS Wrr-r- eE pROVtDEtr Principal Office AddresE: City: zlp: Phone: Office HourslDays: pcnnS,lu.*L t 'o ttlb E. {rv- & {4*^*, M,?ci. S/So r 6rl -bst-r3t M- F g'4 Other Office Addresr: t'*' ZIE; Phone: Offlce Hourslllays: J.bol \$cLl* l*,, S+ P. [l* Soet1 bq l- bJt - lc tl ,rr{ -F F. Other Office Address: \) City: Zlp: Phone: Offbe Hours/tray*:

Otfter OfficeAddress: City: zlq: Phone: Oflbe HourslDays:

Other Offlce Address: Glty: zip: Phone: O'fflc€ HourslDrye:

SECTION 3 - BASIS FOR APPLICATION Checl( all that Check eech box to indicete the of tralnlng you have completed & attach proof. aoolv. trATE(Slr Advqnced education program accredited by ADA that provides training in deep ?It3* bttn sedation and general anestheela \*t Formal training in aitrrray management {.s +/f3 -blt+ Minimum of one year of adrranced training in anesthesiology in a training program ?1t3 - tall+ approved by the board Y.5 SECTION 4 -ADVANCED GARDIAC UFE SUPPORT (ACLs} GERTIFICATION Name of Course: Locatlon: ACLs t^s]r* c k- (.,u.r(.a t tf t{e* s *o,^ tclool *} il..^fgL- DeE of Course: Date Certification Expirer: l, tlAt ttt I/3 U tq Lic. # o Sent to ACC: Peer Eval: Fee #7\W fiW 0 3o Permit # Approved by ACC: State Ver.r ACLS (,G o5 Itsue Date: Temp# Inspedion: Res. Ver Form Brd Approved: T. lssue Date: lnspedion Fee: Res. Cert Name of Appticant ( tv I ,^. G r^^S - sEcrloN s - DENTAL EDUGATToN, TRAttutNG & ExpERtEttcE trrilTtc (tr uelTtat scnoot; From (!totYr|: To (tlofYr!: I I n ] ucrs,,n{- oJ: f6 tr,}c^ 6b/rt ctty, stErE: to'*rc^ (,^f,* ** '*fftt.t{' ru"u I-{iFHPUATE TFiAINING. taf 'v nuacl::!1py'otycnrr cettificate of mmpletion foreacfr postgradur rte program you heve completed Name of Training Proqram: Addrese: t'd6r*", State: Sttnn*rq. llLr h" G PR Aeu S{. s*r[L L4 o+, Phone: snecialtv: From (MoIYr): To {Mo/Yr}: *zo-B?s- Bt*-1 a P f(' FsA-lt ) nt- l l7 t -) Typeof Training: fl lntern ffResident E F€iloyy fJ Other (Be $pecific!: NaEte of Training Program: Addrese:-1-Ioo City:. Stafie: I ffi l{*^t{*^ Co,*, u4. sJ l,{".^+ L,-- T+ Phon:: Speciatty: ! *q . i From (Mo/Yr): To {Mo/Yr}: +B 6u-u-*s"rr O A^l bwfi.=,.. o+1 t\ oLltt Type of rralningr E tntern EfResident E Fefiow H ottrer (Be $pecific]: ' J I,FITILINI'LOSY OF AGTIV]TIES Provlde a dtmnologhal [dnC ';\drd, nt6c rtar gep h rnc. tndudr rno,ura hratqriuv d ! lla lslmoith . vcen, lulilHi mr-;;,A;;. rdd6i .rr.* or p"p"r, r

% r{(,uvtryaL(lqailon From (hlo/Yrl: To (Mo/Yrl: Qenny*l pr*+l*'Sw**^, lt rgt.*I X.***_, Lh*ttl^ 4.K+- a?:* outtT tl .fl*grrl-i &*sL'^. * eT ll\ oLl14

StrL I IIJN E - DEEP SEDATIOTU'GENERAL ANE$THESIA EXPERIENGE YES you E d ruo A. t}o have a licenee, permit, or regietrafion b perfiorm sedation in any o*o J'S.,.ilErI*-*t- sul<19 lf yet, epecfy state(s| and permlt number(s "**-IE B' Do you #* Il lto coneider yourself engaged in the uee of deep *datlon/general aneethesia in your profieeslonal praclce? E YEs C' Have you ever had patient d,o any mortalfi or other incident that resulbd in the temporary or p€rmanent or inJyry requiring fiyslcal mental hospltalization of the palient durlng, or aB a result of, your uee oi anti[nrity premedtcagon, nltrous oxide inhalation analgeeia, moderate sodation or d6lp sedationlgeneritaneethesie? #* tr NO D. Do you plan to use deep sedation/generalanesthesia in pediatric patients?

d"=t tr NO E. Do you plan to ueedeep sedation/generalanerilrerla in rnedically oompromleed pagents? s4t tr NO F. Do you plan to engage in enteral moderaE eedetion? dr* fI NO G. Do you plan b engage in parenteral moderate sedation? wnT oru!3 and ancfiatb tdlnqllas atD you plan utllza or b utlza for lrd.tbn puiFa..? pEvldc dcds (M hh8tEddl, cic,) attrdt 'nqca sqatEta 8l|o!t tf nccrrsary. rnd N rkc--s o ulc/&r.l..rt, trt t".r".1, pa.r"r , [&]*;r.t*< Name of FacilityAddress lll { SEGTION 7 - AUXILIARY FERBOITINEL ' oLl,^*.r.lo. A dsntist adminl ding sadrtim in lowa nuGt doqrmrnt rnd lnsllt that allauxiliry pd3onn€l hava c€r0icalon ln bldc lfe suppdrt (BLs) and arD capablo of edmhi8Hng balilr lib support, Ploes! liEl bslotv th€ mmo(E),leffierirgh&Etiql numb.r, and BLS rt'Miqt dlels of .llad0ary pgliulnd. Name; Licensel BLS Certification DaE BLS Certification Reoistation #: Date: ExPites: d r.. ll,tL q |.Sft,^ Q.olts - ("\elnq altLllv ol t tit"$ trtrame: LlcENEET BL$ Certtfication Dab BLS Geftiftcation ReEiehation #: Date: Exeitetr, S L.c*, ('*^ t .t- fJA - og rlLl ltil- ltt" /*otg Nernei t I Ltcenss, BLS Gertificatisn Deb BLS Gcrtification Reoistation #: DaE: Ext}heB: rttnn<, l{*r. flf\[ - r;rQt?{ ll ttl ll- ' otil.frtk Name: I Licenseil BLS Geilification DaE BLS Certification Reqiatation #: u#'I ExPires: AAA*^ Ct+"{esl.r G?n.A- iI19t ttultle il/)frtg Neme: Llcence, ELB Gsrtlftcutlun DsE ELS Gsrtlflcutlon Reglstation #: Date: Expires:

Name: Lhense/ BLS Certification Da& ELS Certiflcation Hegietation #: Date: Expire*:

Nemc: LieensE ELS C6rtification tretE BLS Ceftifieetion Reglsfration #: DaE: Expires:

Narne: License/ BLS Certification DaE BLSCertification Reglsfratlon #: Date: Erplres:

SECTION 8 - FAGILITIE$ & EQUIPITIENT Eadl V ln UhlGh you pclforn mdafion must bo proDrdy rqubpcd. Copy hls plgr and cfiiplrtr tu rarh facsty, You mry apply hr 8n rxlmlihr of any'io ot thssa FwiCms. Th! Board may grsnt ttla €renpfm f it emh8 treL L a na nable boab lbrtho abnptm. YES NO l* your dental office properly maintained and equipped with thefollowlng: {tr 1. An operating rmm large enough b adcquately aceommodah the patient on a table or in an operating chalr and permit an operfring team consieting of at leaEt three individuah to move freely about the patienf,? dn 2. An opratlng table or chalr that permlt* the patlent to be posittoned so the operatlng team can malntaln the alruray, qulckty alter the patient pooition in an emergency, and provide a firm platform for the manryement of cardiopulmonary reeurcitdion? t' tr 3. A lighting system that is adequate to permit evaluation of the patient's skin and mucosal color and a backup lighting systern that k batGry pqvvered and sf strfficient intensity b permit completion of any operation undenvay at the of general power failure? b/E 4. Suction equipment that permits aspiration of the oral and pharyngeal cavities and a backup euction deviee? dtr 5. An oxygen delivery eystem wlth adequah fullface maeks and appropriate connectors that is capable of delivering oxygen to the patient under poaitive preasure, together with an adequate backup syetem? {tr G. A reaorrery ares tfiat has avalleble oxligen, adcquate llghffng, sucflon, and electrlel oufrets? (The rceowry aflgfi ean bs tfte operating room.) N/tr 7. ls the patient able to beobserved by a member of the etaff at all time during tre recovery period? VrI 8. Aneathelaor analgesia systeme coded to preventaccidental admlnistration of thewrong gm and equipped with afail safe mechanism? dtr 9. EKG monitor? d,n 10. l*aryngoscope and blades? M,tr I 1. Endotracheal tubes? M,il 12. Magillforceps? {.D 13. Oralainuays? d,tr {4. Shthoscope? {-tr 15. A blood pressure monitoring device? {.r: 16. A pulm oximeter? {tr 17. Emergency drugs that are not explred? d n, 18. A defihrillato,r (an automated defibrillator ie recommended)? trd 19. Do you employ volatile liquld anesthetics and a vaporizer {i.e. Halothane, Enflurane, lsoflurane}? J.' 20. ln the ;pacc provldcd, list tfts number of nttrouc oxlde lnhslefron analgesta rmltr In youl faclllty. AND SUBMIT FOR Name of icant bO t \^r c*s h ,n I*^ EI. SECTION 7 - AUXILIARY PERSOHNEI A d!n08t sdmlnistrdns sodalim ln lol,a llnlst doorment and ensura rhatiiiaudtfr p€rEnn.t havo cdtifcrrton ln oa.*c rr"Gf *,in,*n* badD ltf€ arpott neesc ttr* tctow i;G)iilG tr nir.6i 6;JlsIl.d- ilb.r, el.s ;;,;r; foit'rg * arr d*rary EF*,$ "rd

***(ff$W* Date: oEA., l/tt{tL Resltbation fi fu * o& ,'le , tlR/ tL Licencd Reuisrationl('.il- * d t g3J Dare: tlte/lL BLS Certification saH fi | tllll'

SEGTION 8 - FACILITIE$ E EQUIPIIIENT Esrh iadflry h whltfi vou D. lmr ld8ton muli be p(oPcrly rqulppcd. copy thls pagc yqr end oorptrt! br rldr lhaflBr. rEy lpply lbr 111 ffirrddr of ilry of th{o prwisrm.. Tha Bosd m8y grEri tre'","r9ii"i n-il,i,rr,n#-i#.J L r."ui*iui *cro,l;;;il;:- " YI]B llo ll yow ftnt t offlc pcp.rly mJ,r*rln .t and.qulpFd fi& th.lblcwha: w U t'3.H::Iglgl"grSllg-:t1tl*1y-:99:1T"deo!. p_.r.lt ol.l nul or tr !n oF.dns chrtr.rd p..mtrrt , ffire t m conrrtng ot * tut rrrie rndtvuuer b mo'ro-6;,t !d;ni't Fd;d'-'--* gf " Et 2' An oFr.ftrg i.th qdldr [Ei Frm]b olg paolmb b to- |. oF..rftg ct.r lh. p.is paltbn Doatllqlr.t hrn can nll dn tt.rln .y,$ clry ./ ta an rin*grcy, iro prqaae ihm prrotri ril $a-dfi;;r d'diEiJi-r,rorr.ry,*,,*naorn Ef tr 3' A lbhong rylbn lhlr L .d€qu.b to P.rmlt.v.hdon of lh. p. cnf. .trtn .nd mucc.l 610r .d r Dckrp ltghtne .y5im rd or lutnd6r ffil;fov mma tnbmw t prrmniiinoeoon -nr;*t{qr-und;rrd; tl. rn olgror.r pory.r EI a. sucrbn lqurpmr rha[ prnrt - tl .3 ].non or [r orar rld phryng.c csvrih3 !t|.t r bcroD 3ucdfi &vra.? V tr !' an drgrn .lsllv.ry rysbm wllh d.qu.b tull f*. nt..k! r|d .pprop.lr! oflr.cb.t- - - lhd L c.Fbb ot d.ltv.rlry * und.. patflw prr3ur., - orygq! b , ffi fu.irr xr,tfi r, drque d&rip syrcmi g f. tr A rav*y.rrltr.t hr rrdtr dyaq!. drryn fightng, ]roior, rta.|!aihr, arnrat? (Tta tEoEry|'r cl| b!,!a _ opare0llg ron.l {t ?. b the prt',t.bte to be ob*n A by. m.mb.r dtt. ri!fi rtCl tm3s durlE Oa rsry Frtod? d A 8' aneorc-Lo. m.lg.tL ryttrrn co&.|bFGn.cddonudmii3taioioift.wrol{g-rldlql|hF.twltrrtut,.f. ^ macNl.nl3m? d^ n 9. EKo modbr? {, D lo. L.ryngEcoo. rnd bl!rh3? ilr E ll. Emotahldtub..? d- u rz. rr{Nlior6'? ilf 11 ls. oratd ay.? il, n tt. sir&acope? ill tr 15. A btood pllr.rtr mqttb ne .trvb.? V,n E laAnrh.odnlgbr? dl E t7. ErErg.nca druer ltet Er€ llot srDlld? Ef E Va. euwntw (.n aftmlu dG,tbdtllbr b r@mir€nd.d)? tr 10. Do you .llrpby t/olr0b tqllE rn .$rdc. etd I v.porlu (t.o. Hdo0r$r., En tur.nq..Yt ttoflurrl.p rwarsasttsr r ^g 80. ln the space providcd, Ilst the --A number of nthous orfde fnhalaffon analgesla unltr In 5pur faelltty. ANB SUBMIT SECIOr ! - f liou a|lgwor Yss b any ol ths qu6lim6 balow, at@r a full orplanallon. R.ed iho ln6tucdons for imporlint ddltdtona YES NO l. Do you cur.nlty h.rl. m.dlc.l condlllon lhat h arrymy lltlFll! oI [mlb you, aHllty b pde den06y ulth r!-.n bb tr w .td[ and rar.m 2, Are you currently engaged in the illegalor improper useof drugs or other chemical subetances? trV 3. Do you currently use alcohol, drugs, or other chemical substancm thatwould ln any way impair ot llmit your ability to tr w practlce dentietry with reasonable ekilland sffety? 4. lf YES to any of the above, are you receiving ongoing treatment or participation in a monitoring program that reduces or NIA eliminahs ttre limitations or impairments cauaed by either your medicalconditlon or use of alcohol, druge, or otfiet chemical n tr eubstancee?

5. Have you ever been requeehd to repeat a portion of any profeeelonal training programltchool? trV 6. t{.v. you Gl.r l!a.$,!d . s.flr[rg, Eprlnmd. or b-n pld on Fobrton ]lng. proft.doltll t lnlm Prog]Jlrrfdl@l? E d 7. Have you ever voluntarily surrendered a licenee or permit ieeued b you by any professional licensing agency? trv 7& It trB, s|3 . llc.n!. .fLchllnry acton Frdlng {dmt you, o. vrre you ufihr lnr,!.ielton by r llcrllalne {.ltst .l tr.l tr , tr tn!.Ol3 volunt ry.uJtan Lr d lharEwr tnomd? ^ 8. A.ld. ftom o|rllnqy tnlflC ]tqulttltl.nt3 d plcior.hlp, have your dlnlc.l .adrrlL. .y.r n.!lt ll$Ld, tu.plrd.d, r.vol(.d, tr ur not !.rEd, rcluntrrlltr rdlnqullhd. or tuqet b ofti dbct lnrry or pro!.0onrry ctrdtuom? e. Hr3 mtl judrdlcdon ot lll. Unlts l S-&. or odl.r nrton .v.r llmltsd, n tloE, xr.rn d, c.rLurEd, Cao.d on probrlbn, tr Zf aurpddad, or ravolad a llcaDa. or Fmit you tr*? lO H.!rs yoll rv.r !..! ndflert deny rrrrg€. nfa qranctyo{ ly r llo.mlE or dElpllmr, {3rEy ot ]ryJurLdlotor| ol tr tr V U.s. or otll naton? 11. Have you ever ben denied a Drug Enforcement Adminlrtration {DEA} or etat6 controlled substance registration cetsllcate or tr w har your controlled substance registration evet been placed on probafion, suepanded, voluntarily surrendered or revoked? SECTION {0. AFF]trAVIT OF APPUCANT STATE: -F I e rr^-q l, he bdow nsm€d epplaEr , hoGby d8clar! und* p€nalg of psdury lhat I !m thc pEl8at d€.cdbrd snd klGntfi.d in th|3 lpdic.lim md lh.l my amwsl8 and allliai8manb madc by ine ofi thlr lpplhafron and aocomisrylng drdmantr € tlc rnd onElt Should ltumhh lnylusq lnfurmdon, or have auhtsntiol or rsion, I horlb ag[Ee t|at aidl ad lhal condtXc Gause for d€nld, llsgnakrl or twocatbn ot my liccnao or psrit to Eoitb &€p r.datb/Ean$rl t ifo arUan Urat f t On not psrqtally compl€io th! hrrlEing sf,pllcatbn lh8t I hav! tully raad sd confrtBl€d €sd! qlsdon and acoornpEnyng rntwc, €nd takc nJ[ rclpondufiry fo.6ll €nlrvlts Eontdncd lo ihh appllo€tbn. I und€Eiand thet I hav€ no l€0rl autho ty b admlnlsti dr€p scdalin/gflErd anoslhqla un{l I patnit ht8 brBr grfftad. I undorEtard lhlt my tldllty ls sut lo an m{it! ernluaton prlor i: the bsuanoe of i pernlt and by .ubmltdng en lppflcatlon lor a &Ep .adstlm/g.?l.rrl rn6lhels pdr lt, I hd€bi com,tt fo eJdr en anlualin, ln adrffisr, I und€ntstA fiat I ftey ts aloFrf f a proiaodond rwlualhn es of tho aldlcatlon lirocla8 Ths p.!6!esimal €valrEton she[ be oorduaird by tra Anr3olrds oodsntlds Commitho and indudo, at a minimrn, oraluadon of my knowlsdgc 6f cro mgnrgrmrnt 8nd arwry managsmrnt I c.rriry t|Ef I altl t?l|od and c4rblB of .dltllnkii! hg Advr'lcld CaIdlao uf! Suppod rnd nl8i I omploy tufid€nt .uxillaty P.rtmnC b rlrl* h monlkilrg a plttcnt urdlr dc€p scds0on/gerorsl draaihada. SuGh polsomrl s'r talncd h rnd capru! d r9!lbtl_n!- rld ltgna, alalltng h emergcni procsduna, snd ld;nhi'tlnng baelc lih rupport. I undeBtand thlt a dat'rat psrformlllg a procgdlr! lbr shidl dqrp lrdadon/edrel ereedloai tr Uetng otlployld CEI not rdrninbbr fta g6n6rd anrafift l'td mfi or lh3 pat€if trftdn $a prtleloa erd ardlttnca d ,i last tuo qudifu ,u,dlLry pccomol. I !m s{y!r6 tM Fltsua to lom Adrdnhlallva Codo 66(H9,9(158) I rrult rlpon any !d!rcr8a ocdxlsncos l6lst3d to ttc usa ot rada oll. I h6Eby auhodza the 1rl6ss6 of eny end all lnfomadon and llcords thE Boad shall d€6m pcdinant b$6 e\rslualim of ttls app ceton, 8nd rlrfl aDdy b Ulc tiosrd srch ruGord8 End lrlfor;|stfi as Gquerild lbr ardusuqr ol my qualltoatom fu ! p.tintt io sdlrrinldlr acdatm ln lh. Et!i! ol lora I und.Ghnd fi.i b€!.d o'l arllustloD d drdd$als, fadllfl.!, rqlrlFrclll, pErsonnd, 8nd p.oc.durs, lhc Eoed may phor ?lrtrlc0ons oi th. p.nt t I turfio. stEl8 til,t I hlw lled the rul6s |llebd lo tha usr of 8.drtdr, rs desodb€d ln 650 low' Adrlrgsfradlr Cods Cha .r 29. I horsby aor€s to €t de by the hs lrd rulcs perldrln! !o tle pr.c[qe of dontlrty and drcp 8€da[on gensal E tGaOEsh h 0l€ dde of lowa. MUST BE SIGNED IN SIGNATURE-H:9K^,--s OF APPLICAfrT PRESENGE OF NOTAHY > A NOTARY $EAL i,rils fifoo*lvor /J414aI{ ,YEAR frOll

'i!:i'iit:" SHANEII t6- GASION -'if,j E ff'WWpuBLrc NAME (TypED pRtNrED) MY COMI{ISSION EXPIRES: Orenv oR fr':f 3 t'":xlii;i.t1l? fl , I3l Morch 25, 2018 +?, ru iiji$\" I5r*, {rr rq C*srwt trl 06, AGLS Iil$THUGT*H ,A G I, S rN$TBuGT0q , TG TCID# Alnsrican lt4zsll- ACLS tleart flsl A*6sciefitin. TC -- -4F lnstru#tsr lqitfp+s"*2m6s"*" PEEL TC -"13.t *.* .i "' 4[l' ???1 { HTflE 99: *ffiurtan-ffi***-"** --' *ff ---*-- ' succestr"nry completed trt cog$fr'€- afld.. rn* abor* inAiviJuuilros - lnstructor s h+8tlt E:-' stfln e,raruation ln aocarcgrEs ivith the curriculurn of lhs Ar$ltsen AssoEratim ASL,$ lngructar Fhioflrsrtlt' Holder's

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i IOWA DEf-lTAt BOARD {90 $,W. 8m $roeq'$ulte D, I},at Holnat, lowa 60${t$"1fi87 Plrona 1615] I8l{157 Fax (815) 281.7S88 tg_tp:l8urr!#,f,sntalEoard.lowa.uoy,,

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vERlFlcATroH oF FOSTGRIDUATE RES|DEI|GY PROGRAT

sEcTtot{ I *APPHCAI{T II{FOR}! TEr,l * lnrtucilone Ccrrplete Ecdon I ard mdt fih fu' to fiG Posgraduato Pmgram Dhottor lbr vadficaton sf your'poetsrqdu*E Uainfuq. . .1. ilAIrlE {Flr*t illddlc, I-affi $ulflx, Formerlllaldrn}:

To obleln a pannit to edrnlni*ter deep aedationJgancral snartheele ln loun;$e lact Dsntll Boerd laquirus that the applicent rubnitcuidanct of havhg comCc{ad an appmvcd Botfiridurtr hrlning progrim or ottrar lormel Eaining progrffii npprowd by trr Borrd, Thc rpdicanft rignaUru bdow suhori':at hs rdsm; of any lnlbrmattrr, fanrraHa roilrarui*. dlrady b thr lorua Dcntsl Botd tl ihc addrm ebon. 3/,\IH.a1

trlAirE OF POSTGRAOUATE PROGRAiI IIIRECTOR:

THIS PO$TGRADUATE FROCRAilI{S APPROVED OB AGCRETIITEO 19 TEACH POSTGRADUATE DEiITAL OR TIEDICAL EDIIC,ATIOiI BY Of{E OF THE FOLLO$flilG; F(r,r*r"""uenrarAuocraron' ffilstrbn 0n Wnhl ftCrsCr+CIrh0n fl Accrrdltr[on Co$ndl ior Grdrffi Hcdtcel Educaton dftrAmcfiEcn ilrdcrl Arroclilon {AffAl; or H eaucrton Commtlbr d tt* Amprlcan OrEopd*c Atroc{etsr {AOAI. NAIIE AND LOCATION OF POSTGRADUATE PROGRAII: t Sulrgttl6 "tt3- {,frle- 43t

T. DID THE IFFUCAI{T 8AI}EFACTORILY COIiPLETE NlE AEOVE FffiTGEADIJATE TRAINIITI0 PROGRAH? If no. phata an** 0n \thflJ( {D qrft&.u+e on vlfrl }Dtl E OlD THE APFLICAIUT EVER RECEffE AIIIAR}IIMi OE REPRIT'AIIID, OR BEET.I PI*ACET} OttI PHOBANOH DURIHG ITIE TRAIilIHG PROCRiII? lf p*, plcarc Wlaln. T. WA$ THE AFPH$AT{T EVER REQUESTEtr TO HEPEAT A FORNOT.I OF THE IRAIHIHG PBOGFATI? If YIct, flcAru a$EiN. 4. DQES TTIE PROBRAITI PftOVIDE FORTTIALTRAITTIING IH AIR}ITAY TIAIIAGETrIEHT? II No. flcata I:qIAIN. E6t* H ilo g. DoEs rHE pRoGRAfl pRovrDE A iururuit oF ottrE yEAR oF AovAIrrcED TfiATNhIB ril AHEsruEstoLoGy AffD RELATEtr AC*DEHIC SUBJECTS HEfoilO IHE UNDERGRADUATE DEI{TAL LEl/EL? lf no, dmtg G#aft

I turltrr ffifilI ffithr eEow nrntod q,frlcrnt lur demonrtrfrd oomprtency ln arrd dap $amofllgrfirill rn*lhcrh IESIGIIATTIEE: DATE: , , 'it^4*t t/I/r T RHCHIVEM

IOWA DENTAL BOARD MAY 1 7 2017 400 S.W. 8th Street, Suite D, Des Moines, lowa 50309-il687 Phone (515) 281-5157 Fax (51s) 281-7969 IOWA DENJAL BOARD 4 http :/furuyw.dental board. iowa.gov

" f1 ,i\' \:i ntAPPLEATION r Etvrt I FOR MODERATE SEDATION PERMIT ,::i' I r

SECTIOH,I * APPLICAHT INFORMAT|ON Instructions I Phase read the accompanying instructions prior to completing this form. Answer each question. lf not applicable, mark "N/A." Full Legal Namer (Last, First, Middle, Suffix| $ernin4 , Vristrn Eliz,tbr.4a OthEr Hames Used: (e.9. Maiden) Home E-mail: Work E+nai!: fllurrrty kr,r+tn Ui,rn;nEp g mnil . bw info@tri e#erinvl . &o'lw Hom€ Addr€ss: citu:' Home Phone: 1111 }{ burua l'n* fitt?uqvt iA Swat 56? ffi? tjty License Number: lssue Date: Erpiration Date: Type of Practice: 0 gJf6 8 ( rtnewnl - 1-/b f;-tl - ts ?efrern SECTION 2 ; LOCATION(S} IN IOIIIIA WHERE MODERATE SEDATION SERVICES ARE PROVIDED Princioa! Offi ce Address: Cltv: Zip: Phone: Offlce Houns/Days: 1?fr0 Asbrry Fd Prbvqv+ 5LOOL Trq 556 Lltl q-5 / A\-Th Other Office Address: Gity: zip: Phone: Office Hours/Days: ?'*-*"

Other Office Address: Gity: zip: Phone: *"".':-lts/DaYs: g-F

Other 0ffice Address: City: Zip: Phone: Office Hours-lDays: ..,+ -." 4-"F"" Other Office Address: City: zip: Phone: Office Hours/Days:

SECTION 3 - BASIS FOR APPLICATION Check if Check each box to indicate the type of training you have completed. DArE(S): comoleted. Moderate Sedation Training Program that meets ADA Guidelines for Teaching Pain Gontrol and Sedation to Dentists of at least 60 hours and 20 patient experiences kfCompleted rfuf n-tlr ln ADA-accredited Residency Program that includes moderate sedation training E Completed You must have training in moderate sedation AND one of the following: '/lLq lff Formal training In ainuay management; OR M Completed Moderate sedation experience at graduate level, approved by the Board I Compteted sEcTtoN 4 - ADVANCED CARD|AG L|FE SUPPORT (AGLS) CERTIFIGATION Name of Course: -E[-1;t*,Location: ftt,Ls krhfi'cah'r^ intlwdtr Fil Wllo l+atf i{-r-l talus,n, ilT Date of Course: Date Certification Expires: 114 lt7 llMq t,:l:t::lt:t::: Lic. # Sent to ACC: lnspection ree #Soo # ri{D:::::ri:: llq'tO ,iglt.:,tt:), Permit # Approved by ACC: lnsoection Fee Pd: ACLS ::tDr,rrrir,, !(li::!!:!!i: O.,, lssue Date: Temp # ASA 3/4? Form AJB Brd Approved: T. Issue Date: Pediatric? Peer Eval Name of Apprica nt {r,s/rd. F!r.r,|,ry, - SECTIOI{ 5 - iliODERATE SEDATIOH TRAIHIHG IHFORil|ATIOH Type of Frogram:

fl po*Eoduate Residency Program ffi Continuing Education Program fl Ottr*r Board-approved program, speciff: Nameof TrainingProgram: Amu;ran So"itl,t rfrr Addrees: GTtV:' state: nn' o { 4n'slh #l1ltiy'ai i ii: ^;"'s;t*fi;i,1;' ru 3 ,rl/*in 5l fn jtrs r ot ilf Type of Exferlence: Jweyl,'s $fi + fuurt ,{ fiidartir lra in lNl ( /trlu *t, drwr*,slr*fr'nnt) pnh*tl mkt t t'l dral 5"9wy tlthle @51 Length of Tralning: . -rw\v'Da&{s} Gompleted: I Meke fir/n - s/s/rr Humbgr of Patient Gontact Hour: To,tal t{umber of Supervhed 7z $edation Ceeer: 21 S VeS E I{O l. Dld you sati#rctorily eomphte the above fiaining program? EI YES EI XO 2. Dos the pogram include at least sirty (S0) houns of dldeciic trelntng ln paln and anxleft EI YES E fO 3. Doe* the program include managEtnont of et lea*t I0 ctinlcal pailents? As part of the currlculum, aru tlre follwing concepts and procedurer trught: p VfS E tO rt. phystcat evetuation; EIYES E XO S.rVeedafion; EIYES fl Ho 6. Airway rnanagement; E YES E XO 7. Honttortng; and El YES E l{O L Beric life supportand en*rgemy flrf,nagernent E YE$ E ItO 0. Doet the program lnclude cllnlcal experlence ln ffineslng compromtEcd etflrays? El YE$ E XO 10. Docs the program provXde hainlng orerperience in rnanaglng moderafieredation In pedlrtrtc patlents?

EI YES El fO {1. Does the program provide tralning or experience in nranaging moderate sedation in ASA category 3 or 4 patlent*? Pbalg atlath lha Epploprlata brn b vglry tour modsrab lsdaton tsainitu. Applcen! uho rEh,od $6 tsainffg h a postra&laE r€aidonry pmgfln mu3t he!.e fiir p@raduels proel.m dlrciof cofipM Form A" ln dlthn, atbdr a copy olyourc.lticeb of coo e! of 0|6 loGtersdlab Prcgram. AF0lcartl! uho r€celvld l,|otfrinhg in a 6rm.l modorab raddm cord rhgaftciiim progr'n mu* nine m proOdrn Oieoranpm FmT B. SECTION 6 - ililODERATE SEDATION EI(FERIEIT|CE E ves E A. Do you have a llcense, pemtq or reglstration to perform moderete sedaffon ln any other state? lf yes, speclfy state(s) end pennlt il YES EI 1{O B. Do you contider yourcelf engngsd in the use of nroderate sedation ln your profesetona I prrctice? //fiT ftr T

E ves E HO C. {a_ve you ever had any pathnt mortaltty or otlrer incident that resutted in ttre temporary or pcrmanent phy*ical or mental lnfury rcqulfing hoepitallzaton ol the patient durlng, ora$ a rerult of, your use * antlinriety prerrediLffion, nitrour oxide lnhalatlon analgeola, moderaile reddlon or deep eedatiodgengrat ans*the$h? E YES EI r{o D. Do you plan to rrte moderabaedatlon ln pedlatrie paftnta? n YES tr HO E. Do you plan to use moderate ssdatlon ln rnedicalg cornpromi*ed {A$A cetegrory B or*} pathnte? EI YES tr HO F. Ilo you plan to engege In enteral moderab sedation? El vss il iro G. Do you plan to engage in parenteral moderate redation? Wh.t lnlol dnrgr rtld rr€ Edc lctrlllhll. do rou ll!ts o[ etn to dlEa h ,our lIa ol orod.rrb |tlmoo? Ploytd€ doodb (M, mtaMon, eE.) ard atbdr a toger* lnel f n€c€€a8ry. St alluh.r( ehu*

2 Qr. Kristen Berning and Dr. Alexia Oetken work in a general dental practice with their father, Dr. Ted Murray, Who currently holds a moderate sedation permit in the state of lowa.

I lhe following describes the drugs and anesthetic techniques planned to be used for enteral and parenteral sedation in our office of adult patients ASA 1 loderate Class and 2.

I Qral sedation: triazolam (1st choice), diazepam, lorazepam

I

I lV sedation: midazolam, fentanyl

I

I A-dditional medications during lV sedation as needed: Decadron, Zofran, glycopyrrolate

I

I lf some lV sedation cases, a CRNA will be actively involved in performing the sedation. The CRNA also may {se propofol titrated to effect at moderate sedation levels.

I lYitrous oxide- oxygen inhalation will be used in conjunction with many enteral and parenteral sedation cases.

I

I lhe above medication doses will be chosen and titrated to effect based on patient's age, weight, health, medical conditions, anxiety, recommended titration rates, and will stay below maximum recommended doses. Medications will be redosed and titrated as needed following those guidelines.

(Firt p i,fltA il,tl ri; H iit [t I 11 ffir$f As ffi il! k#rtifi fi" fl ffi ffi $ B# tr], ffi mT Amwshffiffi ffim ffiffiffi mm@$fl&$ffiffi LAffi $"ff FH srutPPffiBlT ..ri:-, r:r ,:f -, st. Joseph's Reg. Medical ctr. TC lD # NJ00030 tl,o, il,.=l)lti American I3l',ls^,^-Center Name Heart 703 Main Street ffiffi'Wil',gil',.: .i'' Association* TC lnfo ,Pa.tgrispn, NJ 07503. ,,(973)754-3450

Course Kristen E Berning a;;ti;" St. Joseph's Regional Medical Center above individual has successfully completed the cognitive and lnst. lD # evaluations in lnstructor accordance with the curricutum of the American (gl08:9.6J2!3|T Association Advanced Cardiovascular Life Support (ACLS) I3r"_.___._8"_-u:le_.._{9llg_ _ * _ * Holder's 04-30-2017 04-2019 9rclglqr_. Recommended Renewal Date @ 2015 Amsrican Hsart Association Tampoing with this card will elter its appeafince. 15n 803

;;.i;i;; ;;ilffi*;'***=* il*".,g**",,s"', Please do not lose this card. A .i/15 I 1s_180s f replacement fee of $10 will be charged. 'rB-1, Name of nt Etrot tn Facilitv Address 00 bu, 't h,tn,r{ lfr n sEcnoN z - AUxtLtARY PERSoNNEL / A dontiEt administgtlng mod€rate sodatlon ln loy,a must doqrmont and ensur€ that all auxlllary p€r8onngl hgvg c€rtificaton ln b6sh lib support (BLS) 8nd arr capable of adminbtldng baslc llte support Pleaso llst bslorv th6 namo(s), liconso/r€gistralion numbor, ard BLS cedlflcstlm status of all auxlliary p€rsmn€|. Name: License/ BLS Certification Date BLS Certiflcation ReeistratiP;fi Date: 4--4 _ rq Expires: fraci Jolnspn o3 (,'lT J L lt S - ZAtT Name: License/ BLS Certification Date BLS Certification fu,rtee J t l'tYrs t't- Registratro"frhu Date: -?_ Exptres: z0l? Str:p o jor 3L I t7 5_ Name: Llcense/ BLS Gertificatlon Date BLS Gertificatlon Registratio"En rl Date: Erpires: rtro*l*ny hilfr;rt{ tl 0 11- l i -L-t7 F- ZCiel Hame: License/ BLS Certification Date BLS Gertlflcatlon Registratio"u&flA Date: Erpires: -Ui1 rt*v f{cile,' fr S 001 S- Z -t7 5 Name: License/ BLS Gertlflcatlon Date BLS Certiflcatlon Registrationn'[*[)A Date: Erpircs: rtma^l* hlnnry c q q17 5 -7 _l? 5..Zpl1 Name: License/ BLS Certification Date BLS Certlflcatlon Resisrratio"o, Date: Expires: dwt S ,twwrk'*n _tl _?_C1 S a,n'th,o, ofi A t)A ll q 37 f -? f 7 License/ BLS Certification Date BLS Gertification "^*Tro* Resistration*: Date: Expires: 5 - Fvrtdt 6pfi tZ f b q 5 -z- tl 70lI Name: License/ BLS Certification Date ELS Gertification Registration #: Date: Expires:

SEGTION 8 - FAGIL]TIES & EQUIPMEHT Eadr fr.rlity in whlch you p€rfom moderate s€dation must bs praporly €quipp€d. Copy thls psgo and compht8 for lach tsdlity. You may €pply for a trah,sr of 8ny of lisss pmvi6iona. The Board may grant the rElwr lf lt dstomln€s li6r9 is a tr*onabl€ baslr 6r the walwr.

YES O la your drnt ofilco prcparly mdntlln€d rnd oquippad with tha iollowlng: d A I . An op.Etln! llonr larg. .nough to adoqu{.ly .ccommodab tllr pl0rnt on ! tlbb or ln an opar.Ong chalr and pmlt rn op€rrtlng tarn con.l.dng of rl lar3t two lndlvldullr to mow fi!.ly rbout lh. patl.nt? d A 2. A.l op.rrtlng bblo or chal. thlt p.rmlt! the p8tLnt to ba poaldon d .o lh. op.].dng bam can malntaln iha alrwllt, quld.ly !lt!r tha p.hnt poqldon ln an am.ilancy, lnd prcvld! ! flm datfonn for tha mrnagmant ot cadlopulmon!4r rtauadtrilon? d tr 3. A llehdng ty.bm lhlt l. .doqudo to psrlrtl amlustlon ot lhe pltlonPt rkln rnd muc6d color .nd t backup lbhtng .tEt€m lh.t L b.tory prylltd and of .rficlent lnton.lty to p.rmlt compl.tlon of tny oFrltlon undrrryr .l th. tlm. of glr.nrl powl f.llur.? d tr 4. Suctlon .qulpm.nt lhrt po.|rllt! arpll?totr of th. on.l .nd ph!.lngcrl GIUOE ]td ! b.clarp luctron drylc.? d A 5. an oxtE n dalh,oEr rtfaLm wlth rdaqulb ftill iaca mark! aad aDF.opdrt connactort lhai lt capabh of atallvlrlng dtEan to th. p!0.nt undor poclllw pttr.uro, tog€thrr wllrr an rd.qurt blckup .yrt m? d A 6. A Ecov.ry lrlr thlt h!! lvril.bl. oryEan, drqurto llghdng, tucton, rnd.Lctlcal ou{ot ? (Iho rrcovrly !|u c.n bc lh. op.Edng rcon.) d A 7. l! th. patlcnt rblo to br obcil,td Dy. m.mber otth. lt|ft.t.lt flmaa du.tng lha r.cov.ry p.dod? V tr 8. An.lth.clr or !n!lg.th 3yd.m! codod to prtEnt rccldantrl rdmft .ffilon ot th. [rcng gtro and aqulppad wffi a f.ll !.ir marfimltm? d A 9. ENG nonttor? { n 10. L!rymeo.copc and btado!? { A ,1. Endotracheat tubes? { A t2. Irt.gtlt ,orcop.? d I ls. or.t.tr*.yr? d g r{ sr.thorcoDc? d. E 15. A blood pr.lult monltoilng dovlcr? V tr la A pul.. oxlmd.a d A 17. Emri.ncy drug. th.t llt not .xplrrd? { A 18, A d.fibrllhtor (rn ruiomrt d d€ttbdl.tor l! Ecomnt nd.d)? tr ff f O, Oo you cmploy t alrtllo llquld.nrdhc06 ard a vrportsor (1.o. Haloth.ng Ennur.n.,lroiun n l? V 20. ln tha apaca prlvld.d, liat tho numb.r ot nllrlu3 oid. lnhllatlon altalloaL unlta ln your faclllty. COPY FORM FOR EACH FACILITY sECTl(l 9 - lf you amwEr Yes to any iif ths qlrasfons bebn,-attach d tull eldaiiatkih-;''Read lh6 irlstncualr!:8 foi tunbbrtant Co.fAuci'is; YES NO i , Do you cumr*ly tr.y! ! madi€l condltlon thrt In any way lmpalrt or llmita your rbllity to pttctlc. do lrty wlth ltraombla tr w *lll .nd !.fttr? 2. Are you currently engaged in the illegal or lmproper use of drugs or other chemical substances? trw 3. Do you currently use alcohol, drugs, or other chemical substances that would in any way impair or limit your ability to tr ET practice dentlstry with reasonable skill and safety?

1. lf YES to any of the above, are you receiving ongoing treatment or participatlon ln a monitorlng program that reduces or NIA eliminates the llmltatlons or impairments caused hy either your medical condition or use of alcohol, drugs, or other chemlcal substances? tr d 5. Have you ever been requested to repeat a portion of any professional training program/school? trd 6. Haya you ovor ncaiwd a uamlng, r€p m.nd, or baan pLcad on prcbation durlng a pluh$loml tralnlng pmg n/achool? tr d 7. Have you ever voluntarily surrendered a license or permit issued to you by any professional licenslng agency? trW 7.. It y.r, w.. . llc.nt. dl.clpllnr,tr tcdon pondh! egrln.l you, or sr! ltou und.r lnwtlgdon by r llc.nrln! .ggncy .t thlt A , W 0m. lh. volunt!ry.untnd.r ot llc.n.o wlr t ndrEd? .ulA 8. Aldo lhom odlnary lnldal rrqulBm.ntr of prccrio[hlp, hrvt your cllnlcal lcdvltLo owr b!!n dnrltad, auapandld, lrwt 4 tr w not ranaw.d, valuntlrlltr Elinqulthad, or.ubloct to o&.r dlrclplln.ry or pnobatm.ty condldm!? 9. Has any jurisdictlon of the United States or other natlon ever llmlted, restrlctedn warned, censured, placed on probation, tr w suspended, or revoked a license or permit you held? 10. H.v! you .v.r b.ln notm.d olany chartf,. ihd lgdnri tlou by ! llc.ltlln! or dltclpllmry lgcncy otanylurl.dlcdon otlh. tr w U.3, or othar nrflon? ll. H!v! lou cE h..o d.nlrd. Dru! Etloncrm.nt Admlnlstra[on (DEA) orltlt cont oll.d lubltrnca nglttrtlon crltllcrb or E V hll tlour contnollad aubsttnca ttgltffilon owr bccn pLcad on prcbdion,3urpandad, voluntarily auntnddrd or ltwk d? SECTION 10. AFFIDAV]T OF APPLICANT

STATE: -F COUNTY: .* { ?ov'/n Dv hufide I, th€ bolow named appllcart, h€Eby dedar6 und€r psnalty of p€dury lhst I am iho p€rson dosorlb€d and ldsntmad h thls appllcadm and that my answorr and all atiatom€nE med€ by mo on thb application and sccomparMng stlachm€nb ar! tu! and coflEd. Should I fumkh anyEls6 ilrb(trstlon, or have Eubdantial ombslon, I helgby agGa that such ad stEll consilt ta causa br dsnlal, suspenclon, or rcvocdon of my llcansa or p€.mlt b prwlds rnod*ai! lodation, I also d6dar! lhat if I did not porsonally complot tl. lbr€golng appllcadon lhat I harr. tully road and coofnn€d aadr qu€qdon and accompenying an3v{sr, and take full r€spon3lblllty for all answorr contain€d in thk applicston. I undeEEnd that I have no hgEl authoriv to admlnbt€r modsr& s€dation unfl a psmit has be€n gnntrd. I undoEtand thst tIry iadllty b lubloct b an on-ar:to er,aluation p.ior b lho l$uanca of a psmit and by submlttng an appllcatlon lor a inod€rate lrdadon p€mit, I hereby consant to sudr an evaluatioo. ln addltbn, I underaland ihat I may bo subl€d b a profession8l €valualim as part of the eppllcatm prccas!. The prcftsrhnd €valuatm Ehall bs conduded by the Ars8lhssi6 Cr€denlisls Crmmlttoe and lndudo, at a mlnlmum, €valuatlon of my krlowl€dgo d cas€ manag€mont and alruay manag€mont. I c6.tfy that I am Uain€d and capaHo of sdminist€ring Ad\rsncod Cadisc Lib Suppod and that I employ suficisnl auxiliary p€lronrol b !aC8i in monltodng a patont undsr moderat! lodatlon. Sudr perro.h€lare tElnod ln and capablc of monlbdng vlblslgns, assBling in gllleE€ncy proa€durB, and administ6ring baslc lib suppo( I undorEtand that a dontlst perft.ming a prccoduro ior *fiidr moderd. s.dstloo ls brlng orHoygd $all not admhistli ths phamacologic aguts and monllor ths palient wihout fi€ pl€s€nc€ and asslstance of at hest om qu6fil€d auxlllsry p€r8onnol. I am ev,are tist pursualrt b lora Administatiw Code 850-29.9(153) I muli Bporl any ad,€G€ occuflances rrlabd b tho ulo of sedallon. I abo und€rgbnd that f modoraE E€dation rgsulE ln a g€nolal an6€thatic stgte, tho rul€a for d€€p s€datodgerE rl enaEth€cla apply. I hercby authorlz€ lho rsl6asa of any and all lnfomaton and r"cods the Bosrd shall d€€m pedlnent b tho evEluaton of lhls apdlcaton, ffd ahall lupply b the Board ruch rgcords gnd lniormation as rEqu66t d fur o\,ralualbn of my qualficdlons lor a prrmlt to sdmlnlEt€. modorEt E€datlon ln lhe stat! of lora. I undor8tand that b€s€d on c\raluatlon ol cl€dentelE, ,Edmss, squhm$t, p€nonnsl, and Eoogdurcs, tho Board ruy pl€ca rusfic0om m thr prnnlt, I fudher strate ihat I hav€ rEad the ruleg relat€d to thg u86 of s€dation and nitoqs o)dde lnhalation analge3la, as d€sqlb€d ln 660 lowa AdmlnlsHvo Code Chspt€r 29. I heleby agree to sbldo by ths laurs 6nd rules pertalnlng to the prsc{lc€ of dohtbtry and rnodor.te !€d6tion in th6 !tat6 of lo'y., MUST BE SIGNED !N SIGNATURE OF APPLICANT PRESENCE OF NOTARY > [,rr/fr* fr*ruv+ NOTARY SEAL suBscRtBED AND SWORN BEFORE ME, TH|S \ )_ DAy OF .ry-\ c-x-{-L , YEAR ?_- \) NOTARY FUBLIC SIGNATURE _) t\lmM.FiilST '1 I(,* rn"' f).-,- 6."x C or n nrr$sron Numbef l2f,i F[or*nv puBltc r{mre fiypED oR nRINTED} MY COMMISSION EXPIRES: My' Commission Er-Sn \(> * Z\t-\ B- J \(.-*^, \rY1 P',q5 tD - >rL-[8 IOWA DENTAL BOARD 400 S.W. 8th Street, Suite D, Des Moines, lowa 50309.+687 Phone (515) 281-5157 Fax (515) 281-7969 * http :/lwww.dentalboar4.iowa.sov

PLEASE TYPE OR PRINT LEGIBLY tH INK.

FORM B: VERIFICATION OF'.MODEEATE SEDATION TFAINING

SECTION I - AFPLICANT INFORMATION lnatucdom - U8a thi! form lt you obtain€d your talnlng ln inodsata s€d8too fiom anothor pGgram that must b€ appro!6d by $€ Boerd (1.c. you dld NOT obtEln your tsair ng ln moderate s€dadoo whlle ln a posEraduais Esld€n6y program). ComplsiE S€cdon 1 and maitUrls lbm O the PloSrsm Dlr€do. fur vsrlfrcatbn of yq/r havlng succEsfully comploted thls training, NAME (First, Middle, Last, Suffix, Former/MaidenL Krislen E lizo"bcfh berti ing (llu,,ray ) MATLING ADDRESS: 'l?o(l rtslury Fr( CITY: fl t zrP coDE: PHONE: /r)?uffut "'*e= 1.ft lzo117 56a f56 ltil To obtain a permlt to adminisi8r rnod€rata sodation In lowa, tho los,a D€ntal Bo6rd rsqulrrs 0|at tho appllcant submlt rvld.nc! of hsvlng cdnpl€figd an apprcrred po8Eraiu.ta trslnlng pogram q ottEr iolrllal talnlng pIogram approv€d by tho Board. Th6 apChanf! slgnatur€ b€low aulhoria! lhc raleaso ofanyinb Eton, favor9blo or otiorf,rlso, dir€cuy to tl€ lowa Oontal Boad at the EddEsg sbove. APPLICANT'S SIGHATURE: DATE: - frrffi* Emn'r 5 5" ZotT SEGTION 2; TO BE COMPI.ETTO AY fMINNG PROCRAI,' DIRECTOR NAME OF PROGRAM DIRECTOR: l-1 ,, Le t* Ee u F-o s' Dnn, HD NAME AND LOCATION OF PROGRAM: PHONE: S f. Ao rer\+'I /2€6 /.tfi4-, H €o (L,rr_ c€Nr€L Qts -"sy ^ 7o I + N tAA-m , pxte tut at *t A Z.o Sa FAX: ?'71-'?ty- Ze?? E-ltlAIL: EFAtutap {?Hrtc. on ;WEB ADDRESS: tTToreH f t#ia4av . O&4 DATES APPLICANT FROM (MO/DAYflfR): TO (MO/DAY/YR): DATE PROGRAM PARTICIPATED IN PROGRAM > Ar?ru zY . ?-o t ? PIAY {, 2*tt CoMPLETED: g/f /t z EGs tr no t. DtD THE AppLtcA T sATtsFAcroRtLy coupLETE THE ABovE TRAr{t G pRocRAr?

@{*a*o,. DoEs rHE FRoGRA co pLy wrrH THE A*ERrcA, DEirraL lasocraro ourDELr Es FoRTEAcHr c pArt{ COI{TROL A D AEDATIO TO DE TtsTS OR DEI{IAL STUDEiITS?

EnEs E No !. DoEs rHE pRocuir t CLUDE AT LEAsr sxry (60) HouRs oF DtDAcnc rRAtt{titc tN pat At{D aitrETy?

ElfEs E o 4. DoEs THE pRocRA |NcLUDE cuntcll ExpERtEI{cE FoR pARTtctpatrg ro succEssFut"Ly raracE iIOOERATE SEDATDN AT LEAST TMNTY (20} PATE]{T8?

AS PART OF THE CURRICULUI, ARE THE FOLLOWING CONCEPTS AI{D PROCEDURES TAUGHT: E{es tr no s. pHylrcAL EvALuATK,N; El4es tr r,ro s. rv sEDAloN; w(erl rc t, ArRwAy A AGEIET{r; trr6 tr no o. o rroRrirc; AirD E(es tr no o. BAsrc uFE suppoRT lrrD E ERGE cy aNAGE E[r. alt no to arw ol !bov.. daaaa att ch . doLllcd aElan.fion.)

llurther certify tly{1nd anove named applicant has demonstrated competency in airway management and moderate sedation. PROGRAM OFECTON SIGNATU#( DATE: 4-/orr*fu ,- r - t7 AMERITAN SOCIETY F(lR THE ADVANTEMENT ()F DAVID CRYSTAL,DDS E)(ECUTrVE SECRETARY ANESTHESIA AND SEDATI(IN IN DENTISTRY 6 EAST IJNTON AVE BOIJND BROOK, N.J. 08805

Phone: 732469-9050 Fax:732-27 I-l9Bs

May 5,2017

This will veriff that KRISTEN BERNNG' D.D.S. successfully completed a comprehensive program in parenteral conscious sedation for dentists. The two- week program, sponsored by the ASAASD, is based upon and abides by American Dental Association standards for teaching sedation in dentistry. The training site is St. Joseph's Regional Medical Center, an academic ffiliate of New York Medical College. St. Joseph's sponsors CODA accredited advansed education progftIms in general practice dentisfiry, pediatric dentistry, ffid oral and morillofacial surgery as well as an ACGME accredited residency program in anesthesiology.

The sedation course for dentists was held from April 24th- May sth, 2017 with 60 hours of didactics including lectures, seminars, videotaped presentations, hands-on instruction and simulations. Successful completion of the program requires full participation in a minimum of 20 clinical cases.

A* D David Crystal, DDS Hillel Ephros, DMD, MD, Course Director Executive Secretary, ASAASD OMS Program Director Chairman St. Joseph's Regional Medical

Dominick Lu, DDS President, ASAASD Chairman, Departrnent of Anesthesiology St. Joseph's Regional Medical Center

The American society for the Advancement of Anesthesia and Sedation in Dentistry is an ADA CERP Recognized Provider

* &tlA C. E B F I tr*ilffi#,'ff,t-#tr [tf;ffiEiVEm

IOWA DENTAL BOARD l+lAY 1 7 Zfril rfllr 400 S.W. 8th Street, Suite D, Des Moines, lowa 50309"4687 Phone (515) 281-51 57 Fax (515) 281-7969 tltg I A[_ http ://www.de ntal board. iowa.s ov *,r;f,,rA l:,[:N"i BOARD

APPLICATION FOR MODERATE SEDATION PERMIT

$ECTION 1 - APPLICANT INFOR]I/IATION lnstructions - Please read the accompa{lying instructions prior to completing this form. Answer each question. lf not applicable, mark "N/A." Full Legal Name: (Last, First, Middle, Suffix) oErld;i' AiExiA,' M H RR'+/ Other Names Used: (e.9. Maiden) Home- E-mail: Work E-mail: (Dtb N/fr i7ii,"o etLen @ 3'na'l'u* infa @ tr;eyeeprtbt al, Home Address City: State: Zip: Home Phone: ;ury -sq? *ag7s fi {f- 4fl4rtR,4 e T Frcsrft EA 5zu a6 License Number: lssue Date: Expiration Date: Type of Practice: DDS * 0f o{7 Ge,v#*t DEruT{trR/ SEGTION 2 - LOCATTON(S) rN |OWA WHERE MODERATE SEDATTON SERVTCES ARE PROVTDED Principal Office Address: City: Zip: Phone: Office* Hours/Davs: f7,3 tvt Tlt 42-oo 4sBapl R-i) Dt,tbtt Qtt E SAeo ?^ SE6-2Atl fr *m'{P/n OthEr Office Address: Gity: zip: Phone: Offlce Hours/Days: ___ NA Other Office Address: City: Zip: .F Phone: Office Hours/Days: f.--

Other Office Address: City: - Zipt Phone: Office Hours/Days:

Other Office Address: City: Zip: Fhone: Office Hours/Days: + - \-r__ -- SECTION 3 - BASIS FOR APPLIGATION Gheck if Check each box to indicate the type of training you have completed. DATE(S): comoleted- * Moderate Sedation Training Program that meets ADA Guidelines for Teaching Pain v* z-{ t-7 ?a compteteo Control and $edation to Dentists of at least 60 hours and 20 patient experiences fi 5-s-/7 ADA-accredited Residency Program that includes moderate sedation training I Completed You must have training in moderate sedation AND one of the following: "f*24-17 h Formal !l *tT training in ainnay management; OR I! Completed .s*_.f Moderate sedation experience at graduate level, approved by the Board I Completed sEcTloN 4 - ADVAHCED CARDTAC L|FE $UppORT (ACLSI CERTIF|CATION Name-i-iL{- of Course: Location: S+ Ke4 p0*l f$edft*l (* Jaseph'r ii'*fimho, i{r' B,b Ber+,n il o) Cen tet., f,.tu*^ N f Date of Course: ./ / Date Ceilification Expires: 4/r<7qot7 Lr/t / 2-o/1 Lic. # Sent to ACC: lnspection ree () #.56ia # l'161A o Permit # Approved by ACC: Inspection Fee Pd: ACLS (}o o lssue Date: Temp # ASA 3/4? Form A/B Brd Approved: T. lssue Date: Pediatric? Peer Eval Name of Applicant ftwvt* ffi, O {rE E/,) SECTIOH 5 - IUIODERATE SEDATIOH TRAI]IIII{G IHFORHATIOH Type of Program: I Postgraduate Residency Progra, H Continuing Education Program n Otner Board-approved program, specifo: l{ame of Training Program: frnertz*tt .fiaA e,+-u AddnBrr: t*'P^fsrsort $tate: tu thlA{r4hceaiet t fu4t*te,sru*g ,an rl .\fdl hr.Fr- th J^of )rri H s+*rr ZpZ lfln,i Sr ,tJtI Tlpe of ExPerienee: I gmnlqhdi eY bc hrE cl,"/q ,j,, I lronr4* *, tr*l*ucfrm; *ltn rYnl Pe-,'et{c L Length of Training: Date(t) Gompleted: .\__A ril/# tl-Iq*D tn *{tT Number of Petient Gontact Houns: Total Humber of Supervimd nrt Sedatlon Cases: '-1 'L 8_O FYES-t U HO 1. Did you satisfac'torily complete the above training progrrm? ilves E uo 2. Does the program includo at least slxty (60I houre of didactic training in pain and anxlety? fr., E no 3. Does the program Include managemcnt of at leart 20 cllnlcal patlents? As part of the currlculum, are the followlng concepE and procedures taught: ilrr* E no 4. Phyrlcal evaluation; ETYES E NO 5.lV sedation; 'g:ves E Ho 6. Airway management; trT ves I--l Ho 7. ilonitorlng; and -dr., E no 8. Basic life tupport and emergenclr management. f,ves E no 9. Doet the progmm include clinical experience in managing Gompromised airvayr? Fr.* E r,ro 10. Does the program provide training or erperience in managing moderate sedation in p+diatric patienh? EYEs Fno 11. Does the program provlde trainlng or experlence ln managlng moderate *datlon in ASA category 3 or 4 patlents? Ploso attadr thr apprcpdsb fom b vstfy rlur modo6ta 8€datibn ieining. &Ellcanb who Ecoivrd thrlr tElCng in a pcEradusfro tBddancy pmgram mult hawlhek pcbraduab prcgram dlEcior cfirdcb Fqn A" ln addlton, stltch a coly of your c€.liicab of coorpbtm ollho po!ts .duaig progrdn. Applicant8 who ]rcsiv€d Olir teining in e furmelmod€rab lrd8Uon contiming €ducatbn prcgiam must hay! tlE prcgtam dilr6r cfiiplsie Form B. SECTION 6 - iTODERATE SEUATIOH EXPERIET{CE tr YEs/Er No A. Do you have a licente, permit, or rtghtration to perform moderate sedation in any other rtate? lf yes, specify state{*} and permit fl YES/^EI HO B. Do you condder youruelf engaged ln ths ure of moderate mdatlon In your profe*slonal practlce?

tr vesprno G. Have you ever had any patient mortality or other incident that resutted in the temporary or pernanont physical or mcntal injury requiring hospltalizatlon of the patient during, or as a rusult of, your use of antianxiety premedication, nitrous oxide inhalation analgssia, moderate sedation or deep *dationlgeneral ansetheeia? E YES dw D. Do you plan to uee moderate eedation in pediatric patients? ! YesEl'no E. Do you plan to usa moderate sedation in medically compromi*ed (ASA category 3 or 4) patients? flves E uo F. Do you plan to engage In enteral moderate *edetlon? El-ves n ruo G. Do you plan to engage in parenteral moderate sedation?

What major drugs and aneethetic techniques do you utilize or plan to utilize in your use of moderate sedation? Provide details (lV, inhalation, etc.) and attach a separate sheet if necessary. ft{t-'t"l'

2 Name of 4/er* rtufh,* Facititv Address t'Z.o 4tlrrnl I Au 'ug SECTION 7 - AUXILIARY PERSONNEL il iZ-DnL A d€ntEt adminkbdng modorato 8€daton in lowa ml'lst document and ensurs that sll euillary p.rsonn€l haw erliflcaton ln baslc lfib suppon (BLS) and ar! capabls of admini8te.lng baslc llio support. Pleeso ll6t below tho nams(s), [conse/r€giltaton numbd, and BLS ccdfrcatlon statu! of all auiliary poEmnc. Hame: License/ BLS Certification Date BLS Certlflcation Peg*traffi/P' Date: Explres: Tiaci JoL*sut* ca b'tT s_ 7 _17 E-Lplf Name: License/ BLS Gertification Date BLS Certiflcation '--"'-"HTiiReoistration #: Dare: Explres: Siepko^e, ,Jo lt^ssr- o $q 3z f-Z_lT {- Zp / ? Name: License/ BLS Certlflcatlon Date BL$ Certiflcatlon frt,{o'r,/ le tifrirl aesistrffif, olTza Date: S* Z*t7 Expires: 5_zo /q Name: t LlcGnsel BLS Certlflcatlon Date BLS Cenlficatlon Resistrat'#'ff7 Date: Expires: A"-Y Pferle, o rooar q*Z-tZ S_ Z,p/7 Name: License/ BLS Gertification Date BLS Gertiflcatlon Resistratiffi Date: Erpires: fr*noln Duhn*y fi qq7 f-Z_/ T g_ Zol f Hame: License/ BLS Certlflcatlon Date BLS Certlflcatlon Registratio"fi'nrt Date: Expires: Sawnniha ^*o.fr* I l? at 5--z_t7 J:-"Lul ? Name: License/ BLS Certification Date BLS Certificatlon Regisrratio"nhiltt Date: Expires: lorr* frrmle t l;t"1 f*Z-i7 t_Z.l f Name: License/ BLS Certification Date BLS Gertification Registration #: Date: Expires:

SECTION 8. FACIL]TIES & EQUTPMENT Each iadllty in wtrich }!u plrfom modorata sodEtion must b€ properly €quippod. Copy thk pags and compl€to tor €8dr fucillty. You rnsy apply ftr I $raiv€r of any of tft€so prwlsions. The B€rd may grant tho mlrr€r if it deErminGa thsra ls a rBasonabl€ basiS for lhe wah€r.

YE$ NO ls your dental office properly maintained and equipped with the following:

tr l. An operatlng room large enough to adequately accommodate the patient on a tabte or in an operating chair and permit an F operating team consisting of at leaet two lndivlduals to move freely about the patlent? { tr 2. An operating table or chalr that permits the patlent to be positioned so the operating team can maintain the alnray, quickly alter the patient position in an emergency, and provide a firm platform for the management of cardiopulmonary resuscitation? tr 3. A llghting system that is adequate to permlt evaluation of the patient's skin and mucosal color and a backup llghtlng system F that Is baftery powered and of sufficlent lntensity to permit completion of any operation undenray at the tlme of general pow€r fallure? ,FtrdE 4. Suction equlpment that permits aspiratlon of the oral and pharyngeal cavities and a backup suctlon devlce? 5. An oxygen dellvery system with adequate full face masks and approprlate connectors that is capable of delivering orygen to the patient under positive pressure, together with an adequate backup system?

6. A recovery area that has available oxygsn, adequate lighting, suction, and electrica! outlsts? (The recovery ar€a can be the /tr operating room.) {tr 7. ls the patlent able to be observed by a member of the staff at all times during the recovery perlod? '1 tr 8. fuiesthesia or analgesia systems coded to prevent accidenta! administration of the wrong gas and equipped with a fai! safe mechanism? dtr 9. EKG monitor? 'ttr 10. Laryngoscope and blades? Frtr 1 1. Endotracheal tubes? Ztr 12. Magill forceps? ttr 13. Oral ainrays? "F-W tri 14. Stethoscope? tr 15. A blood presaure monltorlng device? Etr 16. A pulse oximeter? i t_tr 17. Emergency drugs that are not expired? iltr 18. A defibrillator (an automated defibrillator is rlco-."nded)? 19. Do you employ,,volatile liquid anesthetics and a vaporizer (i.e. Halothane, Enflurane, Isoflurane)? "/ 20. ln the space provided, list the number of nitrous oxide inhalation analgesia units in your facility. BMIT FOR EACH FACILITY g SECTIO - lf ),ou an$iidi Y6s to any of tho qu€stirns below atiadr a full €rplanatlon. R6ad the instuctkiis for importiant dollnllions. YEA NO l. Do tlou cunlnuy hlrr r modlcd condlon ltut ln lnysay lmprl]t or llmltt yourlllllulo pnctlca ahnfhity ulth lt.tombb tr lllll nd .ri!ty? F 2. Ars you eurently engaged In the lllegal or lmprcper ure of drug* or other chemlcal auEtances? Eil 3. Do you currently use alcoho!, drugr, or other chemical aubctances that would in any way lmpalr or limit your ability to tr practlce dentistry with rcasonable eklll end safeffi F

rL ltYES to rry ottll..!or,q.ll yql ttc.tulne ollgotle ttltn.nt or pr'0dp.ton ln. monibfir! !rclrrm lt ]tduc.3 or ,U/n' .llmln.t.th.llmltrtomorlllrp.lnrr r cru..d tydtlr.r ylur nl.alcal condlior ot ua. otalcohol, drug!, or oftrcNl.mlc.l rulatancaa? tr tr 5. Have you ever been requestsd to rcpeat a porton of any professlonal tralnlng programltchool? trF prob.Uoo protaalct l prog a lhv. trou tEr.rc.h,td. tJl, rgt ]lp nr.nq a bxn pbd on &n|ttr. tlrHng nbdloom tr F 7. Hatre you evervoluntarilysurflrndersd a llccnsa or permlt lssued to you by any prtfesslonal llccnslng agency? trrg 7a. lf yes, was e llcense dlsclpllnary actlon pendlng agalnst you, or wGrE you under InvettlgaUon by a llcenclng agency at that orurP tlme the voluntary suntnder of llcense was tandered? f. &H. lhom otdlnary lnltLa ]lqul tt.nL ol Etcbllhlp, lra[ you] dlnlc.l .c IUo .[r h.]! ldt4 turD.nd.d, rrrof!4 tr nd nnff,ad, Etrr rdly [[nquldr.d, orauqaci b odra]dltdpuDry c Drobr omry condldq[? ,fl 9. Has any furisdic,tlon of the Unlted States or other natlon eyer llmlted, rcstlcted, werned, censured, placed on probatlon, tr ,a suspended, or reyoked a licenm or permit you held? lO. HtY. you.v.rb..n nodlLd olsry dlllc iLd.!.[rt you lyr llc.ndng or dbdplllt.ryt nG, sa tnytu]trdlcdqt otttr tr U3. or 0(|l.r nr0on? F ll.litv. tDu ov.r b..r dftt daDugEnf.lrfir.ntAdltrlr.ltrton(DEAIaataiaGonlldl.drtaiancatlebdoncardicataa E hrt yeurcoiiolLd rubatanca ]ralffiqr ayJ laan pLc.d on !.!t 0olt, al|tFod.d, yolmlltlly tltrttndrtd a ,otin F SECTIOH 10 - AFFIDAVIT OF APPLICAilT STATE: COUHTY: T,4 finfi,r7o' I, th. b.lo| nsmrd spplhsrt, hqrby dochE undlr p.nsly of Frllry lhat I am tho Daron d!.crlbrd and t'l€n$f€d h lhb sprlcadon lnd lhlt my ansrr€I3 and all ltatam€nts mado by mo fi hb appllcauon rnd .ccol[duno dbdrmdlts at! hx rlld orllct ShouH I fumbh any lbts hfoflrstm, a havo lubdantlal omkrbn, I hoEby sgrrr lh€t ard! ad lhsl comttub caula ftr &dal. a[pqrbn, or ]s.ocdon d my llcal!€ or psml b prlr,lde mod€rat !€daum. I ebo d.c&rs lhst il I dld mt p.lrqElly omploi. fie brrgdng epf,lcalon tllat I har,3 fiIy llad ard Gontrn d .adr qu€Eton and accom!€nrng arff*, rld tEll ful EaponrlbLg for al fllsal! cdltthd in tl. lpplcdon. I un&niard that I hayo no l€oElanlhodty b eddnha. modrIlb lrdslbn untla pa t ll!! baqr e]rlbd. I lrrd.Iltmd thd ny hclty h qn stb rr m.clta o\raluaum !.lor to 0rs bglsnc! of a pfirit ad by $bmiuing .n lpplcafon b. a mod!.!i! ladEliqr panniq I hqlby Gon!.nt b ardl an svaluanm. h addlton, I undotllrd lhlt I may bo luil.d b ! plofuEslonal oYrlllton r! psi dIE lpdlcatlqr FoaaaE. The pltrftsCqlal evalustion shall be co'l(tucbd by lh! Anc!fiqia Cr€d€ntbb Crornrfibe erd lndu&, at a mHmum, evrlur0oo ol my lqloxilrdgE ot ca!€ Imnag€md and alway managrmant. I csrtfu lhat I am tain.d and capatlo 6f sdmini8Elng Advlnc.d Crdisc Lilb Suppoi rnd 0rat I qrdoy rfidJlt ardtury psonrlll b a$m in monltorlrE a prtl.rt uld{ moder8ta ladaton. SucNr patomot er! falnod ln ard atpobL ot modiodng vfial dgnE, .!!blng ln qru!€nay plocodurrr, and admlnidodng balb llb lupoort I undasiend lhd . dq d p.rftlldng e glcadur3 fta uhidl modallb ladalion i. b€hg .lllblEd drall nd edminiEtor thc phannacologb agont! anat monabr fic pddrt ulthout thr plllqlca and ehbnc. ol d halt mc queliad irdllsry prltonnrl. I am auErr lhat pun drt b lom Admhiltrtiua Oodo 650-29.0(153) I muli llpo w sdv.lla ocorlrlE lllrbd b tha uae d r€datibn. I also undorstand that tt nod6rsb !€ddon l€ldb h ! g€n€ral arEtholc !tab, thr riIC lbr d..p !.d!don&€nsd gr..Ord! apdy. I h€Gby au$odzs th€ lBlaale of any and sll lnlb,mddr 8nd l€cad! tl. Bcd &ar plI{natt b tr ruhddt af i$ apdcathn, rnd Crrll anpply b th. Bo€rd sudr llcord! and ffi,ndon ar rlqu.dad lbr.lrallrfon of my qrdiaaloG br a Fr t b a&nnElr mod.rab r.datlon ln th3 rt t! ol lom. I undlEtand that ba!.d on rvaluatha ol cttdmtah,lbdll[.4 aqulFncnt, ps!fin€|, tld prGArE, $o &8td may pbo lrGliadom on tha parnt

I turtho. ltate thst I haw 13€d lh€ rulcs rrlat€d to ths u.s of sedato.l 8nd nibous o0ddo hlElsfon analg€ala, a! dosqlb€d ln 650 low AdminkbE0vo Code Chaptor 29. lh.Gby agEo to abido byths laus and ruhs port ining btho pEcdcs ot ddrt!tsy 8nd modorata !6datbn ln tha stab of lom.

MUST BE SIGNED IN SIGNATUREoFAPPLIGANT PRESEHGE OF HOTARY > W -LO HOTARY SEAL suBscRrBED AHf,swoRH BEFoRE ME, rHrs DAy oF , vEAR rh---- l5 IftAy l7 fl I 4 a-or*nv uc ftr t oR pRtHrED} { ifY coirHlsslolr EXPIRES; JruE {Tf Knea* f, ai,pe lL-f-/1 Dr. Kristen Berning and Dr. Alexia Oetken work in a general dental practice with their father, Dr. Ted Murray, who currently holds a moderate sedation permit in the state of lowa.

, lhe following describes the drugs and anesthetic techniques planned to be used for enteral and parenteral moderate sedation in our office of adult patients ASA Class 1 and 2.

I Oral sedation. triazolam (1't choice), diazepam, lorazepam

l[ sedation: midazolam, fentanyl

I Additional medications during lV sedation as needed: Decadron, Zofran, glycopyrrolate I

i lp some lV sedation cases, a CRNA will be actively involved in performing the sedatlon. The CRNA also may use propofol titrated to effect at moderate sedation levels.

Nitrous oxide- oxygen inhalation will be used in conjunction with many enteral and parenteral sedation cases.

lhe above medication doses will be chosen and titrated to effect based on patient's age, weight, health, medical conditions, anxiety, recommended titration rates, and will stay below maximum recommended doses. Medications will be redosed and titrated as needed following those guidelines.

rJ fl"FI Fit ri'j!] r'r',i\ A ffi tfl At R! rE E ui G lA m m B 0 [flAqffi E=qn ryBgi - " Ir\iiriltitri.r.t riiii{tfdliittlfui\trA$Gfl.l]Lri\m fl-E[jH s-llffrPPE)[,!iT UqF- **.*!-.l#+*:: TC lD # - t'' Training., St. Joseph,s Reg. Medical Ctr. NJ00030 .:,.i, , , l American Center Name ,'-,\\'l .'lll ll rr"-l il /i ,.:, -. ;,--.::l .'-.. Fleart loi Mffi-sd;a*- f itti',,., -.,,,.r',\ii i] ,-1.] ....,.;,,, Associatiot'1, TC ii,-'l. *i ijii y.li1:,:)il tnio i :.Patgrson, NJ 07503.-' ' ':''(9.13\754-3450 r, ,l' i[.]ii r il l''r;-r Ii-' lr'ii t,.lrr'l l,-, :1',:y-TlTl **a-:ffi;;;;.;*,,",.-. -_-.---.- lnst' lD # The above individual has successfully completed the cognitive.and lnstructor American evaluations in accordance with ihe curriculum of the __ .( 010-80_67_2_43-2 ) skills I1I9__ .__ _Iou_qf-8"_qgqlle-_ _ _-"_._ ___ Hearl Association Advanced cardiovascular Life support (A0LS), eroorffi-J Holder's o-2017 04'207'9 _s-tqlt{9-- Recommended Rerrewai Date o20,l5AmericanHeartAssoolationTampeingwithlhiscardwillalteritsappearence.IS-1803

urity features to protect against forgery' Please do not lose this card. A ls-r*,B replacement fee of $10 will be charged. IOWA DENTAL BOARD 400 S.W. 8th Street, Suite D, Des Moines, lowa 50309-+687 q Phone (515) 281-5157 Fax (515) 281-7969 http ://www.de ntalboard.iowa. gov

PLEASE TYPE OR PRINT LEGIBLY IN INK.

F O R M B,: V-E R,l F 1 tO N,-. F, M O D EllrIE S E D A'T I O N TRA I N I N G 9,1, f IN A CONTINUING EDUCATION PROGRAM

SECTIOI.I 1 - APPLICANT INFORIIATION lmtruadona - U€o thls lbrm f you obtainod your kaining h modsrato sldatlon fiiom anolhor Flgram that must b€ appro,€d by th€ Bo6rd (l3. y dld NOT obtain lEur tglnlng ln mod€rata r€dalio.r rxhile in I poBEraduais ]gsldency prcgram). Complste S€c{on I snd ]tlail thb lbm b th6 Program Dlr€do. h. rr€dticatior of your havlng succsstully complstod his Uaining. NAME (First, Middle, Last, Suffix, Former/Maiden): frlerrL M*r*y fletfi.e^ MATLTNGADDRESS: fzoo fitlury Rd CITY: A. t STATE: I A ZIP CODE: R n PHONE: lJorhuq Ue /rt t PDOL fr61-55b-z7// To obtraln a perfiit b admlnisbr mod€rato sadatlon ln lo$,a, tho lof,a Dontal Board rrqulr6 that th€ sppllcart submit addence of harrm cfiDl€bd an appmvod poeEiaduate talnlng program or olh6r fonnal taining program apgovsd by tne Board. Th€ apdlcants Elgnaturr bdoy, authode $o Igloalo of any lnlumalion, favorabl€ or otrorlxlso, dirEty to the loura Dental Boad at th€ addEss abovc.

NAME OF PROGRAM DIREGTOR: (lt t-(81* €f L{fzot, bHD / frD NAME AND LOCATION OF PROGRAM: PHONE: S,T. {OS#H'( R.fCroN"nL YltDt(nL- C€*76;rt ?ts.zry Zo{o

FAX:q-?'?*tY'f E-ttlAlL: Ep l+ r?,o{ WEBADDRE$S: -ZL?l &o _ sT tlnc. o+€4 d f fof #l*t ltr.tzz?J . rs&& DATES APPLICANT FROM (II4O/DAY/YR): TO (MO/DAY/YR): DATE PROGRAM PARTICIPATED !H PRffiRAM > -l /2, {r- r/r/rz COMPLETED: S IT/rI trGs tr rc r. THE AppucA T aATEFAGToRtLy co pLETE THE ABot E TRAiII{G pRocRA ?

EGs tr no z, mEa rHE pRoGRr corapLywlTH THE A ERTcAI{ DEitrAL Ass{rcrATro curDEur{Es FoR TEAcHrr{G pAr{ OOI{TROL A D 3EDATIO]{ TO DE TISTS OR DE TAL STI.IDENTS? dt=s tr *o a. DoEs rHE pRoGRA rircLUDE AT LEAsr axry (Go) HouR3 oF Dro crc rR r{r[o rN plr At{D AtooETrl

@ YEs El No + DoEs rHE pRoGRAlr I{CLUDE cLNtcaL ExpERtENcE FoR pARTlctpAr{Tg ro auccEsaFULLy ltAt{AGE iToDERATE SEDAT|O]{ [{ AT LEAST TWE Ty (ZD pATtEr{Ts?

AS PART OF THE CURRICULU , ARE THE FOLLOWI G COI{CEPIS A D PR(rcEDURES TAT'GHT: Efus tr no s. pHystcAL EvALuATToN; dYes E lo e. v sEDATtoN; 7YE8 El XO 7. ATRWAY iTANAGE Et{T; AYEs El o s. KrlrroRr o; A D dvrs tr o s. Blsrc LIFE suppoRr Ar{D Ef,ERGENsy aNAGETET{r.

Itt no to anv of aboya. pblaa dtach r dciallod Gxplanadon.l

I further certify thaf ffiabove named applicant has demonstrated competency in alruray management and moileiate sedation. P Ro,GRAWRF6{oR s tG N Ar u RE : DATE: 4 T-r- l) t

AMERITAl'l S(I(IETY F(lR THE ADVANTEMENT (}F DAVID CRYSTAL,DDS EXECUTTVE SECRETARY ANESTHESIA AND STDATI()N IN DENTISTRY 5 EAST IJMON AVE BOI.JND BROOK, N.J. 08805

Phone: 732469-9050 Fax:732-21l-1985

May 5,2017

This will veri$, that ALEXIA OETKEN, D.D.S. successfully completed a comprehensive program in parenteral conscious sedation for dentists. The two- week program, sponsored by the ASAASD, is based upon and abides by American Dental Association standards for teaching sedation in dentistry. The training site is St. Joseph's Regional Medical Center, an academic affiliate of New York Medical College. St. Joseph's sponsors CODA accredited advanced education progrilms in general practice dentistry, pediatric dentistry, ffid oral and muillofacial surgery as well as an ACGME accredited residency program in anesthesiology.

The sedation course for dentists was held from April 24th- May sth, 2017 with 60 hor:rs of didactics including lectures, serninars, videotaped presentations, hands-on instnrction and simulations. Successful completion of the program requires full participation in a minimum of 20 clinical cases.

David Crystal, DDS Hillel Ephros, DMD, MD, Course Director Executive S ecretary, ASAASD OMS Program Director Chairuran St. Joseph's Regional Medical )u*,r,)g* Dominick Lu, DDS

The American Society for the Advancement of Anesthesia and Sedation in Dentistry is an ADA CERP Recognized Provider

ADA GE.RF* i E3S[,i#fJ#"'#H