Speaker Disclosure Form

Thank you for speaking at our upcoming conference. Please review our full policy on full disclosure before completing the below form.

Please include any credentials after your last name (eg: MD, DO, MPH, NP, etc)

Disclosure of Financial Relationships within 12 Months of Date of this Form

Disclosure of Unlabeled/Investigational Uses of Products

I have read the NMCAAFP policy on full disclosure. If I have indicated a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts of interest will require the NMCAAFP to identify a replacement.