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    ICOI Fellowship App 0418 RDR

    Uploaded by

    Dr Farhat
    The document provides information and requirements for applying for fellowship with the International Congress of Oral Implantologists (ICOI). Applicants must: 1) Provide documentation of 20 completed implant cases that are at least 1 year post-placement along with supporting documentation. 2) Document over 100 hours of implant education in the last 5 years. 3) Include a letter of recommendation from a current ICOI fellow or diplomate. 4) Submit a CV and pay an application fee of $500 for dentists or $250 for dental technicians. Fellows must also maintain membership, attend meetings, and obtain continuing education to maintain their credential.

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    © All Rights Reserved
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    ICOI Fellowship App 0418 RDR

    Uploaded by

    Dr Farhat
    35 views4 pages
    The document provides information and requirements for applying for fellowship with the International Congress of Oral Implantologists (ICOI). Applicants must: 1) Provide documentation of 20 completed implant cases that are at least 1 year post-placement along with supporting documentation. 2) Document over 100 hours of implant education in the last 5 years. 3) Include a letter of recommendation from a current ICOI fellow or diplomate. 4) Submit a CV and pay an application fee of $500 for dentists or $250 for dental technicians. Fellows must also maintain membership, attend meetings, and obtain continuing education to maintain their credential.

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    ICOI_Fellowship_app_0418_RDR

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    The document provides information and requirements for applying for fellowship with the International Congress of Oral Implantologists (ICOI). Applicants must: 1) Provide documentation of 20 completed implant cases that are at least 1 year post-placement along with supporting documentation. 2) Document over 100 hours of implant education in the last 5 years. 3) Include a letter of recommendation from a current ICOI fellow or diplomate. 4) Submit a CV and pay an application fee of $500 for dentists or $250 for dental technicians. Fellows must also maintain membership, attend meetings, and obtain continuing education to maintain their credential.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    35 views4 pages

    ICOI Fellowship App 0418 RDR

    Uploaded by

    Dr Farhat
    The document provides information and requirements for applying for fellowship with the International Congress of Oral Implantologists (ICOI). Applicants must: 1) Provide documentation of 20 completed implant cases that are at least 1 year post-placement along with supporting documentation. 2) Document over 100 hours of implant education in the last 5 years. 3) Include a letter of recommendation from a current ICOI fellow or diplomate. 4) Submit a CV and pay an application fee of $500 for dentists or $250 for dental technicians. Fellows must also maintain membership, attend meetings, and obtain continuing education to maintain their credential.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 4

    INTERNATIONAL CONGRESS OF ORAL IMPLANTOLOGISTS

    FellowshipApplication
    (TO BE TYPED OR PRINTED)
    Date______________________________________

    1. Name & Degrees ______________________________________________________________________________________________________


    AS YOU WISH IT TO APPEAR ON YOUR FELLOWSHIP CERTIFICATE

    2. Office Address: Street_________________________________________________________________________________________________

    City_________________________________________________________ State________________ Zip___________________

    Country_______________________________________________________________________________________________

    Telephone Number____________________________________________ Fax_______________________________________

    E-mail_________________________________________________________________________________________________

    http://www.
    Web Address:___________________________________________________________________________________________

    Home Address: Street_________________________________________________________________________________________________

    City_________________________________________________________ State________________ Zip___________________

    Country_______________________________________________________________________________________________

    Telephone Number_____________________________________________________________________________________

    . Date and place of birth_________________________________________________________________________________________________


    3
    Day Month Year City State Country

    4. Education

    Predental ______________________________________________________________________________________________________
    Name of College or University Date of Graduation Degree

    Dental ______________________________________________________________________________________________________
    Name of College or University Date of Graduation Degree

    Graduate ______________________________________________________________________________________________________
    Name of College or University Date of Graduation Degree

    5. Country of Licensure:____________________________________________ License #:_____________________________________________

    6. Specialty_____________________________________________________________________________ AGD #__________________________

    7. Number of years a member of the ICOI (Membership is necessary.)__________________________________________________________

    over

    Rev. 04/2018
    Prerequisite Active ICOI Membership

    Who can apply All members who place implants, restore implants and/or fabricate implant prostheses.

    F E L L O W S H I P R E Q U I R E M E N T S :

    1. Provide a listing of twenty (20) completed implant cases. All of which must be at least one (1) year old from implant placement.
    Each patient is one case regardless of the number of implants. However, a restoration can be included as a separate case.
    a. Candidates who place and restore implants: Each patient is one case regardless of the number of implants however a
    restoration can be included as a separate case.
    b. Please provide a listing of twenty (20) successfully completed implant cases (surgery and restoration) all of which must be
    at least one (1) year old from implant placement. All materials should be submitted to the ICOI. There are three ways to
    submit your application: email to [email protected], fax to (973) 783-1175 or mail to the ICOI Central Office.

    2. Provide documentation of completion of one hundred (100) hours or more of implant education (either attending in person or
    completing courses on-line) in the preceding five (5) years.

    3. Provide a letter of recommendation from a current ICOI Fellowship, ICOI Mastership, ICOI Diplomate or member of ICOI’s
    Advanced Credentials Committee.

    4. Submit a current Curriculum Vitae (resume).

    5.
    Fellowship Maintenance Requirement:
    • All ICOI Fellows must maintain their membership in good standing and must attend at least
    one ICOI sponsored or co-sponsored meeting every three (3) years.
    • All ICOI Fellows must also accumulate one hundred (100) hours or more of “implant education” within five (5)
    years after becoming an ICOI Fellow.

    Fellowship
    Processing Fee:  Dentist:  $500.00 (U.S. Funds)    Dental Laboratory Technician:  $250.00 (U.S. Funds)

    Please note: CREDENTIALS MUST BE AWARDED AT AN ICOI SPONSORED OR CO-SPONSORED SYMPOSIUM.


    Check ICOI website at www.icoi.org for complete listing.

    q  I would like to receive my award at the following ICOI meeting:______________________________________________


    (please allow 6 weeks for application and certificate processing)

    q  A separate meeting registration form and fee will be required at the meeting where you will be receiving your award.
    Payment by: q  Check (Make your check payable to the  ICOI)    q Visa    q MasterCard    q  American Express

    Card Number___________________________________________________________________ Exp. Date______________ CVV No._____________

    Signature______________________________________________________________________ Date______________________________________

    PLEASE DIRECT QUESTIONS AND/OR SUBMIT THE APPROPRIATE MATERIALS DIRECTLY TO:

    ICOI Credentials Committee


    55 Lane Road, Suite 305
    Fairfield, NJ 07004

    Phone: 973-783-6300 Fax: 973-783-1175


    E-mail: [email protected]
    INTERNATIONAL CONGRESS OF ORAL IMPLANTOLOGISTS

    Case Documentation Form


    FELLOWSHIP CANDIDATES

    Name __________________________________________________________________________________ Date____________________________

    1. Please list twenty (20) completed implant cases (per patient). All of which must be at least 1 year old on
    this form for Fellowship credentialing.

    • Please note: All candidates who restore and place implants: Please list ten (10) completed implant cases that
    include both surgery and restorations.

    • Practitioner candidates: pre- and post-operative x-rays and clinical photographs of final cases are the basic
    requirements for case documentation.

    • Laboratory technician candidates: photographs or slides of completed cases on master casts or intra-orally are
    the minimum requirement for case documentation.

    • Further documentation may include patient slides or photographs, CT scans, pre-operative evaluation and planning
    forms, lab and restorative work authorization forms, and/or patient treatment consent forms, etc. to further detail a
    case. All materials may be submitted digitally.

    2. Please use the following coding system to describe your cases:

    Type of Implant: Type of Restoration: Current Status:


    Root form—RF Single crown—SCR Satisfactory function—SF
    Small diameter—SD Fixed bridge—FBR Compromised function—CF
    Plate form—PF Overdenture—OD Failed & removed—FR
    Subperiosteal—SP Partial overdenture—POD Lost to recall—LR
    Narrow Ridge—NRI Fixed-detachable prosthesis—FDP


    INTERNATIONAL CONGRESS OF ORAL IMPLANTOLOGISTS

    Case Documentation Form


    Continued
    FELLOWSHIP CANDIDATES

    Name __________________________________________________________________________________ Date____________________________

    Restoration
    Patient’s Maxillary/ Date
    Implant
    Type of

    Type of

    Current
    Status
    ID# or Mandibular Implant(s) Implant Surgical Date of Date Restorative Dental
    Initials Arch Placed Dentist/ Implant Brand Uncovery Restored Dentist Lab

    1.

    2.

    3.

    4.

    5.

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