1. ISOI FELLOWSHIP APPLICATION NAME: ADDRESS: MOBILE No.:

2. 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:

3. CASE 1 Post-Restoration photos Date of photos: FRONTAL PROTRUSIVE OCCLUSAL, MANDIBULAROCCLUSAL, MAXILLARY

4. CASE 1 Photos (continued) Date of photos: LEFT LATERAL VIEWRIGHT LATERAL VIEW RIGHT WORKINGLEFT WORKING

5. 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:

6. INSTRUCTIONS REPEAT SLIDES LIKE CASE 1 FOR CASES 2 to 10 WITH CORRECT CASE NUMBER ON EACH SLIDE. 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 CLICK ‘ insert picture ’ ICON ON TEMPLATE TO ADD 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 WHOSE DIAMETER IS LESS THAN 3 MM. PLEASE DO NOT SUBMIT CASES RESTORED WITH IMPLANTS 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.