Advanced Restorative Reproduction with Neo Fertility : CME Form – The Institute for Restorative Reproductive Medicine

Name

Date

Role in Developing this CME activity, Advanced Restorative Reproduction with Neo Fertility:

Involved in planning learning materials
Involved in delivery and/or development of learning material
Medical Director or Medical Faculty of Neo Fertility
Involved in application process for continuing medical education

Address (City, State, Country)

Email *

DISCLOSURE OF FINANCIAL RELATIONSHIPS WITHIN 12 MONTHS OF DATE OF THIS FORM : *

A . Neither I nor an immediate family member (spouse or partner) has a financial relationship with or a commercial interest.
B. I have or an immediate family member (spouse or partner) has a financial relationship with or interest in a commercial interest. Please check the relationship(s) in the list of options below

(A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.)

Below please indicate the names of the organization(s) with which you have a financial relationship or interest, and the topic areas that correspond to the relationship If more than four relationships, please list on separate piece of paper:

Organization and Type of relationship:

Topic area (s) involved:

Neo Fertility Conflicts of Interest Form for CME Activities

Below please indicate the names of the organization(s) with which you have a financial relationship or interest, and the topic areas that correspond to the relationship If more than four relationships, please list on separate piece of paper: