Diplomate Name: ____________________________________________
- Part 1. Professional Standing Requirement
____ Copy of most recent current, valid and unrestricted Medical or Osteopathic License*
____ Professional standing disclosure questionnaire (Recertification Examination Candidate Application)
____ Proof of current Basic Life Support with External Defibulator Certification
*If Diplomate is licensed to practice medicine in more than one jurisdiction a written and notarized self-declaration that all medical or osteopathic licenses issued to Diplomate in all jurisdictions are current, valid and unrestricted. A sample of the written self declaration is available on-line .
- Part 2. Commitment to Lifelong Learning and Periodic Self-Assessment
Choose and submit 1 of the following options to satisfy part 2:
____ Option One
- ___ ISHRS CME Award satisfies this requirement; for more information contact www.ishrs.org for CME Criteria; or
____ Option Two
- ____ Written Self-declaration of CME attendance (within prior 3-year period; 100 Category I Credits; 50% must be specifically hair related activities sponsored by the ISHRS) View the Self Declaration Of CME Attendance for MOC Requirements.
- ____ Proof of Attendance to one ISHRS Annual Meeting
- ____ Proof of Attendance to an additional ISHRS sponsored hair related meeting (may include another ISHRS Annual Meeting.
- Part 3. Cognitive Expertise (Recertification Examination)
____ Register for MOC Re-certification Examination
____ Pay MOC Re-certification Examination Fee
____ Pass Re-certification Examination
- Part 4. Practice Performance
Choose and submit 1 of the following options to satisfy part 4:
____ Provide proof of an Internal chart review as required by an accrediting agency; or
____ Submit a copy of your patient satisfaction survey results (8 surveys per year for the past three years for a total of 24 surveys). You can download Three-week and One-year Post Op Surveys.