Speaker Disclosure

Speaker Disclosures

Fill out the form below to complete your FCOM Speaker disclosures

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Profile Information

Salutation

First Name*

Last Name*

Credentials

Email Address*

Mobile Number*

Practice Name / Company*

Job Title*

Licenses

Profession

State License Number

License State

AAA Member Number

Disclosure of Interests

FCOM requires that all speakers, faculty and planning committee members complete a Disclosure Statement so that relevant relationships with commercial interests are identified and any potential conflicts of interest are resolved prior to the CME program.

Please note that FCOM defines “relevant” as any relationship/dollar amount in the past 12 months. A commercial interest is any entity that produces, markets, re-sells, or distributes health care goods or services consumed by, or used on, patients.

Consent to Commercial Interests

I DO NOT have a relevant relationship with any commercial interest(s), and neither does my spouse/partner.

I DO have a relevant relationship with a commercial interest(s). Please specify relationships below; indicate if the relationship is for you, your spouse or partner.

Disclosure of commercial interest

Company Name

Relationship

Self, Spouse, or Partner

Disclosure of commercial interest

I WILL NOT be discussing off label/investigational use of a commercial product or device.

I WILL be discussing off label/investigational use of a commercial product or device.

FCOM does not imply that such relationships will prevent the speaker/committee member from making an unbiased presentation/decision. However, it is imperative that such relationships be identified so that FCOM can determine work to resolve any conflict(s) of interest, should one arise.

Signature*

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Today's Date*