1. Title of Talk
Speaker name

2. disclosure information
Speaker Name:
Disclosure of Relevant Financial Relationships
I have the following financial relationships to disclose:
Consultant for: (List company(s) here)
Speaker’s Bureau for: (List company(s) here)
Grant/Research support from: (List company(s) here)
Royalties from: (List company(s) here)
Stockholder in: (List company(s) here)
Honoraria from: (List company(s) here)
Employee of: (List company(s) here)
I have no financial relationships to disclose.
Disclosure of Off-Label and/or investigative uses:
I will discuss the following off label use and/or investigational use in my presentation. (List products/ devices here) OR
I will not discuss off label use and/or investigational use in my presentation. OR

4. Thank you