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Please list any dietary restrictions.

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Affidavit

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Please click, I agree, the uploaded affidavit has been filled out in its entirety, and signed by the participant's supervising dentist. The affidavit includes the supervising dentist's name, the name of the participant, the name and date of the course, the supervising dentist's signature and license number, and date.

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In accordance with Section 1220.245 of the Rules for the Administration of the Dental Practice Act of the State of Illinois, a dental assistant must be at least 18 years of age and has 1000 hours of clinical dental assisting experience or has graduated from a dental assisting program accredited by the Commission on Dental Accreditation of the American Dental Association, or is a currently certified dental assistant as designated by the Dental Assisting National Board, Inc. to perform the task of Monitoring and/or Administrating Nitrous Oxide.

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In accordance with Part 1220 Illinois Dental Practice Act, Section 1220.245 Prescribed Duties of Dental Assistants, and Section 1220.240 Prescribed Duties of Dental Hygienists, assistants, hygienists, and dentists must maintain BLS certification or its equivalent in order to participate in expanded function courses.

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BLS/CPR

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Nitrous Oxide November 1, 2025 SIU

SIU School of Dental Medicine

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