Rebecca.Carlson@iowa.gov
400 SW 8th St. STE D Des Moines, IA 50309
515-725-4112
The Iowa Practitioner Program (IPP) is a confidential monitoring program for dentists, dental hygienists, and dental assistants with impairments.
“Impairment” means an inability, or significant potential for inability, to practice dentistry, dental hygiene, or dental assisting with reasonable safety and skill as a result of alcohol or drug abuse, dependency, or addiction, or any mental or physical disorder or disability. For the purposes of this program, “impairment” does not include sexual dysfunction, sexual addiction, sexual compulsivity, paraphilia, or other sexual disorder.
Full Name
Home Address
Work Address
Date of Self-Report
Have you undergone an evaluation for this condition?
Have you received treatment for this condition?
Board rules specify that the following circumstances may make licensees/registrants ineligible to participate in the Iowa Practitioner Program.
Do any of the items from the list above apply to you?
All of the information in the possession of the Iowa Practitioner Program (IPP) and it's personnel regarding licensees and registrants is confidential. Do you give the IPP permission to inquire about the material facts you have provided in this self-report?
Permission to Inquire
Sign Here
If you have additional questions or concerns, please call 515-725-4112.
confirmation of self-report