Dental Examination Forms

The following material contains those forms used by CITA in the administration of its licensure examinations.  These forms are being provided to assist candidates who might wish to become familiar with their content and usage.  These forms are also provided to candidates, on an as needed basis, during the various stages of CITA’s application and examination process.  These forms are for information purposes only and the forms downloaded from this site are NOT for candidates to bring and use during the examination, with the exception of the Treatment Selection Worksheet and Radiograph/Follow Up Care Forms.

In order to view and/or download the forms, Adobe Acrobat Reader is required.


2015 Application Forms

All candidates who are registering for the ADEX exam in 2015 with CITA must complete the 2015 Dental Candidate Application Form. Additionally, you must complete the appropriate supplemental form (ie: Junior Form, Senior Form, Resident of Record Form), combine the forms into one PDF file, and then upload that file as your "Proof of Graduation" in the "Profile" tab of your online candidate profile.

2015 Undergraduate Dental Student Application Form
2015 Dental Graduate Application Form
2015 Internationally-trained Candidate Application Form
2015 EXAM History Disclosure Form—DENTAL ONLY
Resident of Record (required if you are a graduate student of resident at the site where you are taking the ADEX exam)
Dental Facility Fees


2015 Miscellaneous Examination Forms

Certification of Examination Preparation and Orientation Form
Dental Assisting Form
Interpreter Form
Limitation of Liability Form
Special Accommodations Form
Example of Patient-Based Examination Schedule
Example of Manikin-Based Examination Schedule
Review and Appeals Application


Test Site Facility Information

ECU School of Dental Medicine
LSU School of Dentistry
University of Alabama School of Dentistry
UNC School of Dentistry
UPR School of Dentistry


2014 Periodontal Examination Forms and Grade Sheets

Consent Form
Periodontal Progress Form
Medical History Form
Treatment Selection Worksheet
Treatment Evaluation Form
Pre Treatment Grading Room Request Form
Post Treatment Grading Room Request Form
Instructions to Candidate Form
Radiograph/Follow Up Care Form


2014 Restorative Examination Forms and Grade Sheets

Posterior Restoration Progress Form
Posterior Preparation Request Form
Posterior Restoration Request Form
Class II Radiograph/Follow Up Care Form
Class II Posterior Amalgam Preparation Grade Sheets
Class II Posterior Amalgam Restoration Grade Sheets
Class II Posterior Composite Preparation Grade Sheets
Class II Posterior Composite Restoration Grade Sheets
Class II Posterior Box Preparation Grade Sheets
Class II Posterior Box Restoration Grade Sheets
Lesion Approval Form
Posterior & Anterior Consent Form
Anterior Restorative Progress Form
Anterior Preparation Request Form
Anterior Restoration Request Form
Class III Anterior Preparation Grade Sheets
Class III Anterior Restoration Grade Sheets
Class III Radiograph/Follow Up Care Form
Modification Request Form
Instructions to Candidate
Exposure Processing Form


2014 Manikin Examination Forms and Grade Sheets

Manikin Instructions: General Administrative Considerations
Endodontic Progress Form
Endodontic Anterior Grade Sheets
Endodontic Posterior Grade Sheets
Prosthodontic Progress Form
Prosthodontic - Cast Gold Crown Preparation Grade Sheets
Prosthodontic - Ceramic Crown Preparation Grade Sheets
Prosthodontic - PFM Crown Preparation Grade Sheets