For continuing education (CME and CEU) compliance, please complete the Speaker Disclosure Form.  

Why we ask for this form: We want to make sure our event is transparent, fair, and professional for everyone. This quick form allows you to share any professional or financial connections related to your topic so our audience knows where you are coming from. It also gives us permission to host your session and confirms that you own the rights to the materials you are sharing. Thank you for helping us keep our event compliant and credible!

* Indicates required field

Section 1: Speaker Information

First Name *
Last Name *
Credentials *
Email *
Phone *
Name of Presentation *
Date for the Activity (For prescribed CME Activity purposes) *

Section 2: Conflict of Interest Disclosure

Commercial Interest Name, if any. If none, answer NONE. *
To maintain the integrity of our continuing education programming, all presenters must disclose any financial relationships with commercial interests (e.g., pharmaceutical companies, biomedical device manufacturers, or other corporations) within the past 24 months.
Nature of Commercial Interest *Disclosure of remuneration amount not required Please provide details in a brief paragraph. If none, say none. *
Neither I nor my spouse/partner has any relevant financial relationships with any commercial interests to disclose regarding this event.
Please declare any potential financial relationship you or your spouse may have.

Section 3: Content Validation & Professional Standards

By signing below, I agree to the following: *
Evidence-Based: My presentation will be based on the best available evidence and will not promote a specific proprietary business interest.

Off-Label Use: If I discuss the "off-label" use of any product, I will disclose this to the audience during my presentation.

HIPAA Compliance: I will ensure all patient cases or images are de-identified to protect privacy.

Original Work: I confirm that the materials provided are my own or that I have obtained the necessary permissions for copyrighted material
DIGITAL SIGNATURE *
By providing your digital consent, you agree that this form has been signed by you.