Experience Route - Application Check List

ABHRS APPLICATION: Experience 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:*
E-mail:*
Mobile:*
ALL REQUIREMENTS MUST BE SUBMITTED IN ENGLISH
1.*

Examination Application
(Complete and Submit this Form: https://hipaa.jotform.com/222136177355152)
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/222154003146138
5.*

Current and valid Life Support with External Defibrillator (“BLS/ED”)
certification from 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/222136296106148)
10.*

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

Affidavit of three years private practice experience
(Complete and Submit this Form: https://hipaa.jotform.com/222153905910147)
12.*

Case Log listing 150 cases for most recent three years from the date of your application and should include approximately 4-5 cases per month over the 36 months.
For example; If application is dated August 20, 2020 then case log will include cases from

August 2017 – July 2018 listing 50 cases (4-5 per month totaling 50 cases)
August 2018 – July 2019 listing 50 cases (4-5 per month totaling 50 cases)
August 2019 – July 2020 listing 50 cases (4-5 per month totaling 50 cases) *
Cancelof
13.*

Operative Reports (50) along with completed ABHRS Clinical History Form see example shown here:
https://abhrs.org/wp-content/uploads/2024/09/Case-Log-Sample-9-23-2024.pdf
Cancelof
14.*

Of the 50 Operative Reports, 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 here. (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
15.*

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

ABHRS APPLICATION: Experience Route

ALL REQUIREMENTS MUST BE SUBMITTED IN ENGLISH