Application Check List - 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: *

1.*

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

2.*

Copy of Government-Issued ID

*

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3.*

Copy of M.D. or D.O. License

*

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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/

*

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6.*

Two Reference Letters from physicians who belong to ISHRS and/or ABHRS

*

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7.*

Copy of Curriculum Vitae

*

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8.*

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

9.*

Application Fee payable upon submission of application
Note: Examination fees are payable upon approval of application

*

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10.*

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

*

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11.*

One year fellowship and 70 Case Logs as assistant surgeon see example shown in
this link https://abhrs.org/wp-content/uploads/2022/08/Case-Logs-updated-4.16.14.pdf

*

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12.*

Proof of completed fellowship

*

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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/2022/08/Case-Logs-updated-4.16.14.pdf

*

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15.*

Operative Reports (50) see example shown in this link
https://abhrs.org/wp-content/uploads/2022/08/Sample-Operative-Report.pdf

*

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16.*

Of the 50, 5 must include 10 before and after photos each, photos must be labelled as seen in the examples shown in this link; https://abhrs.org/wp-content/uploads/2022/08/AllPhotoViews-1.pdf

*

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ABHRS APPLICATION: