Fellowship Route - Application Check List

ABHRS APPLICATION:

Fellowship Route
Please use this form as a tool to ensure that all needed information for your application is sent in. In order to submit this form, all checkboxes need to be completed.

Please click save at the bottom if you need to return later to complete the form. An email will be sent to you with a link to continue later.
Applicant Name:*
Email: *
Mobile: *
ALL REQUIREMENTS MUST BE SUBMITTED IN ENGLISH
1.*

Signed Application
(Complete and Submit this Form: https://hipaa.jotform.com/222124314333441)
2.*

Copy of Government-Issued ID
Cancelof
3.*

Copy of M.D. or D.O. License
Cancelof
4.*

Affidavit of clear and unrestricted license(s)
(Complete and Submit this Form: https://hipaa.jotform.com/222136649881160)
5.*

Current and valid Life Support with External Defibrillator (“BLS/ED”)
certification https://www.onlineaha.org/
Cancelof
6.*

Two Reference Letters from physicians who belong to ISHRS and/or ABHRS
Cancelof
7.*

Copy of Curriculum Vitae
Cancelof
8.*

Affidavit of role of hair restoration surgeon
(Complete and Submit this Form: https://hipaa.jotform.com/222135782565156)
9.*

AMA, AOA or FCVS Physician Profile Ordered by applicant from the AMA, AOA or FCVS (waived for physicians outside of US)
Cancelof
10.*

List of Hair Restoration meetings attended over the past three years.
Cancelof
11.*

One year fellowship and 70 Case Logs as assistant surgeon see example shown in https://abhrs.org/wp-content/uploads/2024/09/Case-Log-Sample-9-23-2024.pdf
Cancelof
12.*

Proof of completed fellowship
Cancelof
13.*

ABHRS Affidavit Form
(Complete and Submit this Form: https://hipaa.jotform.com/222135593280049)
14.*

50 Case Logs performed after fellowship see example shown in this link:
https://abhrs.org/wp-content/uploads/2024/09/Case-Log-Sample-9-23-2024.pdf
Cancelof
15.*

Operative Reports (50) along with completed ABHRS Clinical History Form see example shown in this link
https://abhrs.org/wp-content/uploads/2022/08/Sample-Operative-Report.pdf
Cancelof
16.*

Of the 50, 10 must include 7 before and after photos each, 2 immediate post-op photos all 16 photos must be labelled as seen in the examples shown in this link. (One set of 16 photos attached to each of the 10 patient cases totaling 160) Operative Report and Clinical History Form must be attached to each; https://abhrs.org/wp-content/uploads/2022/08/AllPhotoViews-1.pdf
Cancelof
Cancelof
Cancelof
Cancelof
Cancelof
Cancelof
Cancelof
Cancelof
Cancelof
Cancelof
17.*

50 CME Credit Hours related to hair restoration surgery over preceding three (3) years of date of application.
Cancelof
Should be Empty:

ABHRS APPLICATION:

ALL REQUIREMENTS MUST BE SUBMITTED IN ENGLISH