ISOI FELLOWSHIP
APPLICATION
NAME:
ADDRESS:
MOBILE No.:
CASE 1
Name 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, Place
4mm diameter x 10mm length
Blasted surface, Acid-etched, Custom-made etc)
Medical History:
CASE 1 Post-Restoration photos
Date of photos:
FRONTAL
OCCLUSAL, MANDIBULAR
PROTRUSIVE
OCCLUSAL, MAXILLARY
CASE 1 Photos (continued)
Date of photos:
LEFT LATERAL VIEW
RIGHT WORKING
RIGHT LATERAL VIEW
LEFT WORKING
CASE 1 - RADIOGRAPH VIEWS
Pre-op OPG
Date of photo:
Post-restoration (with prosthesis in place)
Date of photo:
Post-surgical OPG (IOPA sufficient for
single implant) Date of photo:
OPG (after 1 year of restoration)
Date of photo:
INSTRUCTIONS

REPEAT SLIDES LIKE CASE 1 FOR CASES 2 to 10 WITH CORRECT
CASE NUMBER ON EACH SLIDE.

CLICK ‘ insert picture ’ ICON ON TEMPLATE TO ADD PICTURES
FROM YOUR COMPUTER.

TOTAL NUMBER OF SLIDES = 41.
1 INTRODUCTION SLIDE + 40 SLIDES.
DO NOT INCLUDE THIS PARTICULAR SLIDE.

PLEASE DO NOT SUBMIT CASES RESTORED WITH IMPLANTS
WHOSE DIAMETER IS LESS THAN 3 MM.

USE ONLY THIS TEMPLATE ALONG WITH ITS LAYOUT,
BACKGROUND & FONTS. DO NOT USE OTHER FORMATS.

IF ANY QUERIES, E-MAIL TO THE SECRETARY, ISOI.