RAOI Fellowship Form

All parts of this application form must be completed and duly signed by the applicant. The completed form together with the applicant’s current CV, a photograph, proof of CE hours and Case Documentation CD should be sent to the address mentioned at the end of the form OR can be uploaded through the upload portal on the website www.RAOI.org

Applicants who are not Members of RAOI or have not renewed their Membership, are required to apply for Membership along with their Fellowship.

Payment for the Fellowship application must be made in advance to the account mentioned on the form. A confirmation of the same must be sent by email to: info@raoi.org

Successful applicants will be given a Fellowship certificate with a validity of 3 years. After 3 years, the Fellowship certificate must be revalidated (Revalidation Fee: $200). This can be done along with renewal of Membership and submission of evidence of 20 CE hours annually in the preceding 3 years. A revalidated certificate will have a validity of 3 years

(Please choose the correct option)

Are you a Member of RAOI? (Membership is necessary)

YES

RAOI Membership Number:

I want to apply for RAOI 3-yr Membership (for new Members only)

SECTION 1 – Applicants Personal Details

Title: Dr.

Date of Birth (dd/mm/yyyy):

First Name:(Required)

Last Name:

Gender(Required)

Male

Female

SECTION 2 – Contact Details

CLINIC Address:

Postcode/Zip code:

Country:

Email:

Mobile:

SECTION 3 – Payment Information

I am paying for (please choose the correct option):

RAOI 3-year Membership AND RAOI Fellowship (US$/€/£ 850) – choose if you are not an ACTIVE RAOI Member

RAOI Fellowship (US$/€/£ 400) - choose if you are an ACTIVE RAOI Member and only applying for Fellowship

RAOI Fellowship Examination Fee (US$/€/£ 200) (mandatory for Fellowship applicants)

RAOI Fellowship will only be awarded at the RAOI Annual conference or a co-sponsored symposium

I would like to receive my Fellowship at the following RAOI symposium: (Please note, a separate registration form and fee will have to be submitted at the relevant symposium where you are receiving your award)

2. Direct Bank transfer to the account detailed below:

Account Name: The Royal Association

Bank Name: Bank of Texas

Account Number: 8096580541

Bank Address: PO Box 29775, Dallas, TX 75229-0775, USA

Bank Swift Code: BAOKUS44

Bank Number: 14

A confirmation of the same must be sent by email to: info@raoi.org

SECTION 4 – Declaration

I, (name of applicant), hereby declare that all the information submitted in this application is accurate and true and the cases submitted have been done by me. I also confirm I have completed the requisite CE hours and submitted copies of the certificates for the same. I understand if any of the information submitted by me is proved otherwise, my application will be rejected, and the payment made by me towards my application will be forfeited.

Signed:

Name:

Date:

Data Privacy

We are committed to ensuring that your privacy is protected. The information you provide here will only be used for the purposes of processing and approving your membership / credential request and obtaining membership / credentialing benefits. In accordance with data protection regulations we require your consent for this. The data for successful applicants will be held on our membership system.

I understand that RAOI will store and use the data I submit here for the purposes of processing my membership / credential request and obtaining membership / credentialing benefits. The RAOI is occasionally asked by employers, government bodies or other similar organisations to verify an individual’s membership/credential status for employment purposes. I consent to The Royal Association of Oral Implantologists providing verification of my membership and credential status to third parties

Signed:

Name:

Date:

RAOI Fellowship Requirements:

1. Case requirements for submission: Candidates must submit documentation of 30 completed cases with at least 1-year follow-up. Details of documentation for the cases are provided on the CASE DOCUMENTATION page of the Fellowship form. All cases must be adequately documented and submitted digitally as a PowerPoint. They can be uploaded through the link:

2. CE hours: Candidates to submit proof of completion of at least 75 CE hours in the preceding 3 years (attained either through online courses or seminars or teaching courses)

3. Photograph and a current Curriculum Vitae

4. RAOI 3-Year Advance Membership Fee: US$/€/£ 450 (if applicable)

5. RAOI Fellowship Application Fee: US$/€/£ 400

6. RAOI Fellowship Examination Fee: US$/€/£ 200

• All fees are strictly non-refundable

RAOI Fellowship Maintenance Requirements:

RAOI Fellows must be active Members to retain their Fellowship. The Fellowship certificate issued will bear a validity of 3 years. After 3 years, Fellows must ensure they renew their RAOI Membership and revalidate their Fellowship (a certificate with a new validity date will be issued upon paying the renewal and revalidation fee). Nonrenewal will result in delisting from the Members and Fellows directory. If the renewal is not done within a year from the date of expiry, past dues will have to be paid should the applicant decide to renew in future. Fees payable at this time to receive a new Fellowship certificate is:

RAOI 3-Year Membership Fee: US$/€/£ 450

RAOI Fellowship Certificate Revalidation Fee: US$/€/£ 200

1. Submit evidence of a minimum of 20 CE hours annually at the time of renewal for revalidation of Fellowship certificate

2. Attendance to at least two RAOI Annual Conference or the National Annual Symposium of the candidate’s specialty in 3 years

CASE DOCUMENTATION FORMAT:

Case number (e.g. Case1)
Patient Initials / Code name (e.g. RT)
Patient medical history
Dental history and current dental status
Pre-operative radiograph and clinical picture
Recommended treatment plan
Date of surgery
Details of Pre-Implant grafting, if carried out. Add relevant clinical picture
Number of implants placed and their location
Augmentation procedure carried out with clinical picture
Post-operative radiograph and clinical picture
Postoperative maintenance
Type of implant restoration
Date of prosthesis delivery
Post prosthesis radiograph and clinical picture
Clinical picture and radiograph of 1-year functional prosthesis

Pointers for submitting your cases

All cases should be documented in a single presentation and saved as a single file. One case equates to one patient.
Remember to label the first slide of every case with the case number and patients initials (e.g. Case1 – RT).
Complete the case documentation template in its entirety for each case. If you do not have the information, provide rationale or if it does not apply, write N.A.
Required radiographs:
- Pre-Op
- Post-Surgical
- Post Prosthetic

- Image with the final restoration(s) in function for a minimum of 1 year

Required photos: (both pre-op and post-op)
- Occlusal view of maxillary and mandibular arch
- Frontal view, left side and right side in maximum intercuspation position (MIP)
- Occlusal views of all implant attachment mechanisms
- Views of tissue surface areas of the removable prostheses
The candidate must ensure due diligence to submit cases that are complete and accurate. The declaration on the last page of the application form must be duly signed. In the event the candidate is found not to have made an honest and accurate submission, the application will be rejected without any refund of fees.

Please send your completed forms, documents and cases to:

Ms. Dolna Saldanha
RAOI Executive Secretary
806 Thomson Road
#16-12 Thomson 800
Singapore 298189
Mobile: +65 8571 6046
Email: dolna@RAOI.org