Relevant Financial Disclosure(s)

<insert speaker name>

Directions:
1) Insert your name above.
2) Choose the disclosure statement that reflects your disclosure status
3) 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)>

1
 (Example 1)
Relevant Financial Disclosure(s)
Jane Doe, MD

• I have nothing to disclose

2
 (Example 2)
Relevant Financial Disclosure(s)
John Doe, MD

• Company 1
- Speaker
- Speaker fee

• Company 2
- Advisory board membert
- Consultant fee