(1) All licensed dentists practicing in this state shall submit a report to the board within thirty days of any incident which results in death or physical or mental injury requiring hospitalization of a patient which occurs in the outpatient facilities of such dentist during, or as a direct result of, general anesthesia, deep sedation, moderate sedation, minimal sedation, or inhalation analgesia.
(2) The incident report shall include, but not be limited to:
(a) A description of the dental procedure;
(b) A description of the preoperative physical condition of the patient;
(c) A list of the drugs and the dosage administered;
(d) A detailed description of the techniques used in administering the drugs;
(e) A description of the incident, including, but not limited to, a detailed description of the symptoms of any complications, the symptoms of onset, and the type of symptoms in the patient;
(f) A description of the treatment instituted;
(g) A description of the patient's response to the treatment; and
(h) A description of the patient's condition on termination of any procedures undertaken.
(3) Failure to submit an incident report as required by this section shall result in the loss of the permit.