Application for Fellowship

Applicant Information
“The only things worth learning...
Are the things you learn after you know it all!!”
- Harry S. Truman
Name and Degrees (As you would like printed on your Fellowship Certificate)

First NameMiddle NameLast NameTitle
Office Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Fax Number
Date of Birth

MonthDayYear
Date
Place of Birth
City, State
Number of years as a member of DOCS Education:
(Membership Required)
ACLS Providership Date of expiration

MonthDayYear
Date
Education

Once application is submitted:

Provide documentation indicating completion of 75 hours or more of Sedation/Pain control instruction in the preceding 5 years. This may include a single ACLS program.A list of 50 completed and documented sedation cases with dates of sedation. each case should be listed on a separate page and include:( Patient code( Do not provide names), Age, Allergies, ASA type, Medications, Route of Sedations: IV, IM, PO, IH. Drugs used and amount given, Vitals before ,during and after the time of sedation administration, Describe patient dismissal disposition.)
Your Course Advisor will be in contact following application submission to collect the $495.00 application fee.
Signature

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** Fellowship certificates remain the property of DOCS Education. Membership will be revoked if the recipient fails to remain in good standing with his/her local dental board of examiners or in the event of suspension, expulsion, resignation, and failure to maintain membership with DOCS Education through renewal of dues of failure to attend DOCS Education symposiums.

Credentials must be awarded at a DOCS Education sponsored symposium. Awardees may attend this meeting at 25% off normal registration. All Fellows are required to attend at least one DOCS Education meeting every two years. Must maintain active membership in DOCS Education.
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Applicant Information