Registration Form
Please remember to include a copy of your CPR, BLS and/or ACLS certification
with your registration form to receive the study materials. Your CPR, BLS or ACLS
certification must be current through your examination date (a minimum of six months).
Allow PSI three weeks to process your application and mail your study materials. For inquiries,
please call PSI at 833-333-4755.
Assistant Information (as it should appear on the certificate):

Fees and Payment
Tuition includes the DAANCE Study
Materials and Examination Fee.
Additional suggested reading: AOMS Office Anesthesia
AEvaluation Manual, 9th edition
Copyright 2018
This additional reading
must be ordered separately.
Substitution/Cancellation
and Refund Policies
All substitutions and cancellations must
be made using the DAANCE Substitutions
and Cancellations Form provided in the
DAANCE Candidate Handbook or on theAAOMS website at AAOMS.org/DAANCE.
Substitutions require the Substitution/Cancellation Form accompanied by acompleted DAANCE Registration Formand a valid CPR, BLS and/or ACLS cardfor the new registrant.
Candidates may reschedule ONE
appointment for examination at nocharge by calling PSI at 833-333-4755
at least two business days prior to thescheduled testing session. A rescheduling
fee of $95 will be charged for any
subsequent appointment changes
within the candidate’s eligibility period.
It is the responsibility of the sponsoring
doctor to notify PSI of the substitution
and to transfer previously provided course
material to the substitute registrant. Newcourse material will not be provided to thesubstitute registrant.
If a cancellation is made before 90 days,
the sponsoring doctor will receive a refund
equal to 50 percent of the registration
fee. Substitutions must be made 30 days
before the candidate’s expiration ofeligibility.
Candidates have six months from theiractivation date to take their examination.
If unsure of the testing deadline date,contact PSI at 833-333-4755.
Email communications will be sent toregistrants. To ensure messages are notoverlooked, registrants are encouraged tocheck their email spam or junk folders formessages from PSI.

†Candidates who wish to take an

examination in Puerto Rico or outside
the United States should submit awritten request containing the desired
testing location along with the required
additional $105 fee with their application.

Please print or typeMr./Ms. First Name

Middle Initial Last Name

Degree(s)/Credentials (e.g., RN, RDA, CDH, etc.)

Registrant Email Address			

Registrant Phone Number(Note: Correspondence about the course and examination will be sent to the email address you
provide here. Any changes to this email address should be provided to PSI using the change
address/email form.)
Have you previously passed in the DAANCE program? q Yes q No
Provide your current practice address information below. Do not provide your homeaddress. It is your responsibility to contact PSI should this information change.
Sponsoring Doctor
Practice Address

Practice Name
Suite #Email		CityStateZIP

Daytime Telephone Number

I certify that the assistant named above will have completed course materials and quizzes
prior to sitting for the Dental Anesthesia Assistant National Certification Examination. I further
certify that the participant named above possesses a valid CPR, BLS and/or ACLS card and will
maintain current CPR, BLS and/or ACLS certification through the date of the examination.
Participant’s Signature

Date

Sponsoring Doctor’s Signature

DateA copy of the participant’s current CPR, BLS and/or ACLS card is enclosed q Y q NPlease indicate the status of your sponsoring surgeon:		Tuition

q AAOMS Member / OMS Sponsor$405

q Other Dental Professional*$605

Specify Specialty______________________________*Non-AAOMS member/sponsoring dental professional must enclose a copy of their valid anesthesia
permit.
q Puerto Rico or International Location†

			 $105
Total Tuition: $_____________PAYMENT BY CREDIT CARD
When paying by credit card, complete the information below and return it with completed
registration form. Fax to: 913-895-4650 Mail to: PSI, 18000 W. 105th St., Olathe, KS 66061
Credit Card: q MasterCard q Visa q Discover q American Express
Name of Cardholder

Credit Card Number

Security Code

Cardholder Signature

Expiration Date

Credit Card Billing Address

CityStateZIPPAYMENT BY CHECKPayment in the form of personal check, company check, cashier’s check or money order must
be made in U.S. currency and payable to PSI Services, Inc. Mail with completed form to:
PSI Candidate Services, 18000 W. 105th St., Olathe, KS 66061

detach here "Registration Form

Dental Anesthesia AssistantNational Certification Exam19