ISOI FELLOWSHIP APPLICATION

NAME:ADDRESS:MOBILE No.:

CASE 1Name of Patient: Age/Sex:

Type of case: (Single/ multiple/ Full Max / Mand.)

Procedure: (Surgical/ Flapless/ CT Guided etc)

Implant: Name & Company, Length & diameter with details, if any(e.g. IMPLANT, XYZ Co, Manufacturer, Place4mm diameter x 10mm length Blasted surface, Acid-etched, Custom-made etc)

Medical History:

CASE 1 Post-Restoration photos

Date of photos:FRONTAL PROTRUSIVE

OCCLUSAL, MANDIBULAR OCCLUSAL, MAXILLARY

CASE 1 Photos (continued)Date of photos:

LEFT LATERAL VIEW RIGHT LATERAL VIEW

RIGHT WORKING LEFT WORKING

CASE 1 - RADIOGRAPH VIEWS

Pre-op OPG

Date of photo:Post-surgical OPG (IOPA sufficient for

single implant) Date of photo:

OPG (after 1 year of restoration)Date of photo:

Post-restoration (with prosthesis in place)Date of photo:

INSTRUCTIONS REPEAT SLIDES LIKE CASE 1 FOR CASES 2 to 10 WITH REPEAT SLIDES LIKE CASE 1 FOR CASES 2 to 10 WITH

CORRECT CASE NUMBER ON EACH SLIDE.CORRECT CASE NUMBER ON EACH SLIDE.

CLICK ‘ insert picture ’ ICON ON TEMPLATE TO ADD CLICK ‘ insert picture ’ ICON ON TEMPLATE TO ADD PICTURES PICTURES

FROM YOUR COMPUTER. FROM YOUR COMPUTER.

TOTAL NUMBER OF SLIDES = 41. TOTAL NUMBER OF SLIDES = 41. 1 INTRODUCTION SLIDE + 40 SLIDES. 1 INTRODUCTION SLIDE + 40 SLIDES. DO NOT INCLUDE THIS PARTICULAR SLIDE.DO NOT INCLUDE THIS PARTICULAR SLIDE.

PLEASE DO NOT SUBMIT CASES RESTORED WITH IMPLANTS PLEASE DO NOT SUBMIT CASES RESTORED WITH IMPLANTS WHOSE DIAMETER IS LESS THAN 3 MM.WHOSE DIAMETER IS LESS THAN 3 MM.

USE ONLY THIS TEMPLATE ALONG WITH ITS LAYOUT,USE ONLY THIS TEMPLATE ALONG WITH ITS LAYOUT, BACKGROUND & FONTS. DO NOT USE OTHER FORMATS.BACKGROUND & FONTS. DO NOT USE OTHER FORMATS.

IF ANY QUERIES, E-MAIL TO THE SECRETARY, ISOI. IF ANY QUERIES, E-MAIL TO THE SECRETARY, ISOI.