Mentor Request Form - International Association for Orthodontics

Name*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office Phone*

Cell Phone*

Fax

Email*

Dental School Attended

Year Graduated

Did you complete a residency?

Location/School or hospital of residency

What year was the Residency completed

What type of Residency was completed

How many hours of orthodontic CE have you completed?

What types of orthodontic courses have you completed? (please check all that apply)

Straight Wire
Functional – Removable
Functional – Fixed
Tip Edge (BEGG)
TMD (Temporal Mandibular Joint Dysfunction)

In your office do you have in office, or access to the following imaging equipment? (please check all that appyl)

Panelipse – Film
Panelipse – Digital
Cephalometric – Digital
Cephalometric – Film
CBCT-3D imaging

CBCT-3D imaging Brand and Model

How are your Cephalometric film traced?

What digital program is used?

In the past, have you performed orthodontic treatment on a patient?

How many cases have you completed?

How many cases are presently in treatment?

Do you take a series of pre and post treatment photographs for your orthodontics patients?

Do you take pre and post treatment Panelipse and Cephalometric radiographs for your orthodontic patients?

Do you take pre and post treatment study models for each of your orthodontic patients?

Below, please add any comments regarding goals you wish to attain within the IAO Mentoring Program:

By signing this form, you acknowledge that you must adhere to all laws and regulations applicable to the mentor program, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) which requires authorization to use and disclosure protected health information in connection with the program.

You agree that the International Association for Orthodontics is not liable for treatment results and outcomes, and you hereby release the IAO, its employees, agents, and representatives from all claims for damages resulting from your participation in the mentor program. You further agree to indemnify, defend, and hold the IAO harmless from any and all claims, suits, actions or proceedings of any kind arising out of, or in connection with your participation in the mentor program, including any claims relating to advice or guidance given in connection with the program.

Signed*

Date*

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Phone

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