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    Declaratio

    Uploaded by

    Priyanka Gandhi

    Copyright:

    © All Rights Reserved
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    Declaratio

    Uploaded by

    Priyanka Gandhi
    13 views1 page

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    declaratio

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    13 views1 page

    Declaratio

    Uploaded by

    Priyanka Gandhi

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
    Download as pdf
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    BOARD CERTIFICATION AND FELLOWSHIP IN, MICRO RESTORATIVE AND ENDODONTICS Candidate/Patient Declaration Form (This declaration must be submitted along with your case history) Candidate’s Name Examination Number Examination Date Patient’s Name Patient’s Date of Birth Candidate Declaration | certify that | have personally carried out the treatment for the patient mentioned above. Candidate’s Signature Date Patient Declaration | understand that the treatment | received has been documented for use in the Fellowship Examination and | agree unconditionally for this to be submitted to the IBMRE. | understand that my /son’s /daughter’s case history may be uploaded to a secure webpage for scrutiny by examiners but that this information will never be in the public domain. In the unlikely event that the board needs to contact me regarding any particulars of my case | agree to IBMRE contacting me directly and confidentially at the address below: Patient’s Name and address: Patients’ Signature Email/Telephone

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