1. Relevant Financial Disclosure(s)
<insert speaker name>
Directions:
Insert your name above.
Choose the disclosure statement that reflects your disclosure status
Delete the other option and all RED text
If NO relevant financial relationships exist, use this statement:
I have nothing to disclose
If ANY relevant financial relationships exist, list the following for each commercial interest:
<insert name of commercial interest>
<insert role (i.e. speaker, advisory board member, consultant)>
<insert what was received? (i.e. honoraria, consultant fees, grant funding)>

2. (Example 1) Relevant Financial Disclosure(s)
Jane Doe, MD
I have nothing to disclose

3. (Example 2) Relevant Financial Disclosure(s)
John Doe, MD
Company 1
Speaker
Speaker fee
Company 2
Advisory board membert
Consultant fee