INDIAN SOCIETY OF ORAL IMPLANTOLOGISTS (Society Register No. 1214 Public Trust Reg. No. F/21368, Mumbai) President Hon. Secretary Dr. Uday Shetty Dr. Amit Gupta (LAST DATE IS 60 DAYS BEFORE CONFERENCE) Application For Diplomate In Oral Implantology ( Please write in capital letters ) Name: As you wish it to appear on you Diplomateship Certificate MEMBERSHIP NO._________________________________ a. Correspondence Address: Telephone nos.: Cell No. Email ID : List at least 100 complete implant cases / or placement of 150 implants with dates of completion: Note: Describe each case on separate pages in binder or loose leaf book format. Case presentations shall include : i. OPG - Pre & 1 year Post ii. Study Models iii. Photographs or Slides iv. Case History & Summary of the Patient. v. Bio Data & Stamp size color photograph of applicant. Case records will be returned on completion of review. Provide documented evidence of implant course / training attended in the past. Diplomateship Fee: Indian members: Rs. 10,000/- Foreign members: US $ 600/- Note : This fee includes a non refundable processing fee of 10% of the above amount. Return this application along with your DD. drawn in favour of "ISOI - Accreditation Fund" payable in Mumbai. Please submit the completed application form along with the requisite fee (preferably by demand draft) & the Case materials to : Dr Amit Gupta Smile care Dental Clinic Shop no 13, 14 Swapnapurti society, Opp Gundecha trillium Behind 101 corner Thakur Village. Kandivali East Mumbai 400101. Mobile : +919821472746 Email: [email protected] / [email protected] Website: www.isoimplant.com BANK DETAILS FOR NEFT/RTGS PAYMENT Title of account : ISOI ACCREDITATION FUND Account No. : 20002170787 Type of account : Saving account IFSC Code : MAHB0000093 Bank Name : Bank of Maharashtra Branch : TH Kataria Marg, Mahim, Mumbai 400016 REQUIREMENTS FOR DIPLOMATSHIP 1. Members of at least 1 year standing are eligible to apply. 2. Fellowship is a mandatory pre-requisite. 3. Diplomateship may be earned through fulfillment of 100 implant cases with 1 year of clinical and radiographic follow-up and on payment of the prescribed fees (a) The applicant's documentation should cover a diversity of cases like single tooth restoration, multiple teeth restorations, distal extension restoration and should include at least 10 cases of full arch restorations, both removable and fixed. (b) The applicant should include use of more than one implant design for rehabilitating patients. (c) The applicant's documentation should also include cases of bone manipulation such as bone splitting, bone augmentation etc. (d) The applicant should also have some paper presentation or publication to his credit. 4. For cases done in an Institution, upto two persons can be given the credit. 5. Application for Diplomateship can be made together with application for Fellowship or after Fellowship is obtained. 6. Enrollment Fee for Diplomateship is Rs.10,000/- (for outstation cheques add Rs.50/- towards Bank Charges) for Indian Member and Dollars 600 for Overseas Member. The fee shall accompany the application form. This fee includes a non-refundable processing fee of 10% of the above amount. Cheques/Demand Draft to be drawn in favour of "ISOI-ACCREDITATION FUND" only. .