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.