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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€general€anesthesia/deep€conscious€sedation€shall€have€theÐ *Ò Ðfollowing€facilities,€properly€maintained€age€appropriate€equipment€and€age€appropriateÐ ¸ Ðmedications€available€during€the€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 Ðat€least€three€individuals€to€freely€move€about€the€patient;€Ðt  ` (#` (# ÐòòÌ€€€€€€€€€€€€€€€€€€óóà0 ` àAn€operating€table€or€chair€which€permits€the€patient€to€be€positioned€so€theÐ @ è  Ðoperating€team€can€maintain€the€patient's€airway,€quickly€alter€the€patient'sÐ & Î  Ðposition€in€an€emergency,€and€provide€a€firm€platform€for€the€administrationÐ  ´  Ðof€basic€life€support;€Ðòš ` (#` (# ÐÐ Ðòò€€€€€€€€€€€€€€€€€€óóà0 ` àA€lighting€system€which€permits€evaluation€of€the€patient's€skin€and€mucosalÐ ¾f Ðcolor€and€a€backup€lighting€system€of€sufficient€intensity€to€permit€completionÐ ¤L Ðof€any€operation€underway€in€the€event€of€a€general€power€failure;€ÐŠ2` (#` (# ÐòòÌ€€€€€€€€€€€€€€€€€€óóà0 ` àSuction€equipment€which€permits€aspiration€of€the€oral€and€pharyngealÐ Vþ Ðcavities€and€a€backup€suction€device€which€will€function€in€the€event€of€aÐ <ä Ðgeneral€power€failure;€Ð"Ê` (#` (# ÐÌòò€€€€€€€€€€€€€€€€€€óóà0 ` àAn€oxygen€delivery€system€with€adequate€full€face€mask€and€appropriateÐ î– Ðconnectors€that€is€capable€of€delivering€high€flow€oxygen€to€the€patient€underÐ Ô| Ðpositive€pressure,€together€with€an€adequate€backup€system;€Ðºb` (#` (# ÐÌòò€€€€€€€€€€€€€€€€€€óóà0 ` àA€nitrous€oxide€delivery€system€with€a€fail„safe€mechanism€that€will€insureÐ †. Ðappropriate€continuous€oxygen€delivery€and€a€scavenger€system;€Ðl` (#` (# ÐÌòò€€€€€€€€€€€€€€€€€€óóà0 ` àA€recovery€area€that€has€available€oxygen,€adequate€lighting,€suction€andÐ 8à Ðelectrical€outlets.€The€recovery€area€can€be€the€operating€room;€Ð Æ  ÐÐ ` (#` (# Ðòò€€€€€€€€€€€€€€€€€€óóà0 ` àSphygmomanometer,€pulse€oximeter,€electrocardiograph€monitor,Ð ê ’" Ðdefibrillator€or€automated€external€defibrillator,€laryngoscope€withÐ Ð!x# ÐÔ_ÔendotrachealÔ_Ô€tubes,€oral€and€nasopharyngeal€airways,€intravenous€fluidÐ ¶"^ $ Ðadministration€equipment;€Ðœ#D!%` (#` (# ÐÌòò€€€€€€€€€€€€€€€€€€óóà0 ` àEmergency€drugs€inclÔ_ÔudingÔ_Ô,€but€not€limited€to:€pharmacologic€antagonistsÐ h%#' Ðappropriate€to€the€drugs€used,€vasopressors,€corticosteroids,Ð N&ö#( Ðbronchodilators,€intravenous€medications€for€treatment€of€cardiac€arrest,Ð 4'Ü$) Ðnarcotic€antagonist,€antihistaminic,€Ô_ÔantiarrhythmicsÔ_Ô,€antihypertensives€andÐ (Â%* Ðanticonvulsants;€andÐ)¨&+` (#` (# ÐÌòò€€€€€€€€€€€€€€€€€€óóà0 ` àA€defibrillator€device.Ð Ì*t(- ÐÐ ` (#` (# ÐÌà  àà ` àà ¸ àà  àà h àà À àà  àòò€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€óóÐ ~-&+0 Ðà  àà ` àà ¸ àà  àà h àà À àà  àSignature€of€ApplicantÐ d. ,1 ÐÐ  J/ò,2 ÐÔ_Ôà@ˆ ˆ ìàò òQUALIFIED€MONITOR€CHECKLISTó óˆÐ X ÐÌà  àA€dentist€who€induces€general€anesthesia/deep€conscious€sedation€shall€monitorÐ *Ò Ðand€record€the€patient's€condition€on€a€contemporaneous€record€or€shall€use€an€assistantÐ ¸ Ðqualified€as€a€monitor€to€monitor€and€record€the€patient's€condition€on€a€contemporaneousÐ öž Ðrecord.€The€trained€personnel€must€have€a€certificate€showing€successful€completion€in€theÐ Ü„ Ðlast€two€years€of€BLS/CPR€training€and€the€American€Association€of€Oral€and€MaxillofacialÐ Âj ÐSurgeons€Office€Anesthesia€Assistant€certification€or€an€equivalent.€No€permit€holder€shallÐ ¨P Ðhave€more€than€one€patient€under€general€anesthesia€at€the€same€time.€Ð Ž 6 ÐÌà  àÌÌòò€€€€€€€€€€€€€€€€€€óóà0 ` àThe€trained€personnel€must€have€a€certificate€showing€successful€completionÐ & Î  Ðin€the€last€two€years€of€BLS/CPR€training€and€the€American€Association€ofÐ  ´  ÐOral€and€Maxillofacial€Surgeons€Office€Anesthesia€Assistant€certification€orÐ òš  Ðan€equivalent.€€(Attach€a€copy€for€our€records)ÐØ€ ` (#` (# ÐÌòò€€€€€€€€€€€€€€€€€€óóà0 ` àTrained€personnel€must€be€able€to€monitor€the€patientððs€blood€pressure,Ð ¤L Ðheart€rate,€respirations€and€oxygen€saturation.Њ2` (#` (# ÐÌòò€€€€€€€€€€€€€€€€€€óóà0 ` àTrained€personnel€must€be€able€to€properly€document€the€patientððs€vitalÐ Vþ Ðsigns.Ð<ä` (#` (# ÐÌÌà  àà ` àà ¸ àà  àà h àà À àà  àòò€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€€óóÐ î– Ðà  àà ` àà ¸ àà  àà h àà À àà  àSignature€of€ApplicantÐ Ô| Ð