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Title of the presentation Moderator Name moderator 1st author / speaker Name fo author or speaker Co-authors Names of co-authors

Conflict of Interest Disclosure Form In accordance with the rules of the Health Care Inspectorate (IGZ) Name: [ enter your name] Affiliation: [ enter your affiliation ] ☐ I have no potential conflict of interest to report I have the following potential conflict(s) of interest to report [please delete the checkboxes to the left that aren’t applicable, then delete this yellow text box] Type of affiliation / financial interest Name of commercial company Receipt of grants/research supports: Receipt of honoraria or consultation fees: Participation in a company sponsored speaker’s bureau: Stock shareholder: Other support (please specify): Scientific advisory board

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