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Name, Degree Academic/Professional Title Affiliation/Institution, City, State, Country

Name, Degree Academic/Professional Title Affiliation/Institution, City, State, Country.

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Name, Degree Academic/Professional Title Affiliation/Institution, City, State, Country

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  1. Name, DegreeAcademic/Professional TitleAffiliation/Institution, City, State, Country I have no financial relationships to disclose within the past 12 months relevant to my presentation The ACCME defines ‘relevant’ financial relationships as financial relationships in any amount occurring within the past 12 months that create a conflict of interest. OR I have financial relationship(s) within the last 12 months relevant to my presentation with: List Commercial Interest(s) and Type of Financial Relationship Grant/ Research Consultant Stockholder Speakers Bureau Other AND My presentation does/does not include discussion of off-label or investigational use (if yes, list company and nature of relationship – e.g. grants, advisory board, etc.) I do/do not intend to reference unlabeled/unapproved uses of drugs or products in my presentation. If yes, identify the product and unlabeled use

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