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àà  àà h àà À àà  à€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€óóÐ Òz  Ðà  àà ` àà ¸ àà  àà h àà À àà  àNotary€PublicÐ ¸` ÐÌMy€Commission€expiresòò€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€óóà0 p àà0Èp(#p(#àà0 È(#È(#àSEALЄ, (# (# ÐÌÌÌPlease€make€check€or€money€order€payable€to€the€West€Virginia€Board€of€DentalÐ Ä ÐExaminers€in€the€amount€of€$600.00€for€the€application€fee,€no€part€of€which€is€refundable,Ð ª Ðand€mail€to€the€West€Virginia€Board€of€Dental€Examiners,€PO€Box€1447,€Crab€Orchard,€WV€Ð è ÐÔ_Ô25827.Ô_ÔÐ  Îv Ðà@ºº!ìàò òFACILITY€CHECK€LISTó óˆÐ X ÐÌà  àA€dentist€who€induces€conscious€sedation€shall€have€the€following€facilities,€properlyÐ *Ò Ðmaintained€age€appropriate€equipment€and€age€appropriate€medications€available€duringÐ ¸ Ðthe€procedures€and€during€recovery:€Ð öž ÐÌÌòò€€€€€€€€€€€€€€€€€€óóà0 ` àAn€operating€room€large€enough€to€adequately€accommodate€the€patient€onÐ ¨P Ðan€operating€table€or€in€an€operating€chair€and€to€allow€an€operating€team€ofÐ Ž 6 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ÐÔ_Ôà@ˆ ˆ ìàò òQUALIFIED€MONITOR€CHECKLISTó óˆÐ X ÐÌà  àThe€dentist€shall€monitor€and€record€the€patient's€condition€or€shall€use€an€assistantÐ *Ò Ðqualified€as€a€monitor€to€monitor€and€record€the€patient's€condition.€A€qualified€monitorÐ ¸ Ðshall€be€present€to€monitor€the€patient€at€all€times.€Ð öž ÐÌÌòò€€€€€€€€€€€€€€€€€€óóà0 ` àThe€trained€personnel€must€have€a€certificate€showing€successful€completionÐ ¨P Ðin€the€last€two€years€of€BLS/CPR€training€and€the€American€Association€ofÐ Ž 6 ÐOral€and€Maxillofacial€Surgeons€Office€Anesthesia€Assistant€certification€orÐ t   Ðan€equivalent.€€(Attach€a€copy€for€our€records)ÐZ  ` (#` (# ÐÌòò€€€€€€€€€€€€€€€€€€óóà0 ` àTrained€personnel€must€be€able€to€monitor€the€patientððs€blood€pressure,Ð & Î  Ðheart€rate,€respirations€and€oxygen€saturation.Ð ´ ` (#` (# ÐÌòò€€€€€€€€€€€€€€€€€€óóà0 ` àTrained€personnel€must€be€able€to€properly€document€the€patientððs€vitalР؀  Ðsigns.оf` (#` (# ÐÌÌà  àà ` àà ¸ àà  àà h àà À àà  àòò€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€óóÐ p Ðà  àà ` àà ¸ àà  àà h àà À àà  àSignature€of€ApplicantÐ Vþ Ð