If a death, any serious complication or any injury occurs which may have resulted from the administration of general anesthesia/deep conscious sedation, conscious sedation/moderate sedation, anxiolysis/minimal sedation, or relative analgesia/minimal sedation, the licensee performing the dental procedure shall submit a written detailed report to the board within seventy-two hours of the incident along with copies of the patient's original complete dental records. If the anesthetic agent was administered by a person other than the person performing the dental procedure, that person shall also submit a detailed written report. The detailed report(s) shall include:
(1) Name, age and address of patient;
(2) Name of the licensee and other persons present during the incident along with their names and addresses;
(3) Address where the incident took place;
(4) Type of anesthesia and dosages of drugs administered to the patient including local anesthesia;
(5) A narrative description of the incident including approximate times and evolution of symptoms; and
(6) The anesthesia record and the signed informed consent form for the anesthesia.