Destination CME Presenter Registration
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BIOGRAPHICAL INFORMATION
PRESENTATION INFORMATION






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HONORARIUM




DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM
 
A Commercial Interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

 

*when you select 'YES' you will be contacted by MAFP staff to provide additional information.



DISCLOSURE OF UNLABELED/ INVESTIGATIONAL USES OF PRODUCTS

The content of my material(s)/presentation(s) in this CME activity includes discussion of unapproved or investigational uses of products or devices.

*when you select 'YES' please list




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