Q: Has your license to practice in this state or any other state been denied, restricted, limited, suspended or revoked; have you ever been reprimanded by a state licensing agency; or are any of these actions pending with respect to your license? A: No
Q: Has your DEA Registration ever been restricted, limited, suspended or revoked, or are any of these actions pending with respect to your DEA Registration? A: No
Q: Have your hospital privileges, if any, ever been revoked, suspended, reduced, or not renewed; have disciplinary proceedings ever been instituted against you; or are any of these actions now pending with respect to your hospital privileges? A: No
Q: Have you ever voluntarily relinquished hospital privileges, DEA Registration, academic appointments or any other professional status while an investigation was conducted? A: No
Q: Have any complaints been filed against you with a dental/professional society? A: No
Q: Have any professional liability judgments been entered against you, including arbitration awards or are there professional liability suits currently pending against you? A: No
Q: Have any professional claim settlements, not involving litigation or arbitration, been paid by you or paid on your behalf? A: No
Q: Has your professional liability insurance ever been canceled or has professional liability insurance ever been denied? ®Yes ®No A: No
Q: Have you ever been convicted of a felony or do you have any felony or misdemeanor charges pending (other than minor traffic offenses)? A: No
Q: Do you now have or have you had a chemical dependency/substance abuse problem? A: No