Destination CME 2018 Session Submission
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Biographical Information

Please provide the following information exactly as it should be included in event materials.

Presentation Information

Please provide the following information exactly as it should be included in event materials.



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Permission for Images in Slides

Permission is needed to use images, including cartoons and photos, in presentation slides. Fair Use does not apply when presenting for an Academy Continuing Medical Education session. Learn more about Copyright & Permission FAQs from the American Academy of Family Physicians.




Honorarium

Presenters may not accept compensation from other sources.






Disclosures

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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