Abstract Submission Form
Title:
Click here to enter your abstract title.
Author Details – Presenting Author
First Name:
Click here to enter the author’s first name.
Last Name:
Click here to enter the author’s last name.
Credential(s):
Click here to enter the author’s credentials (i.e., MD, PhD, RDCS, RCS, etc.)
Institution Name:
Click here to enter the institution name.
City & State/Province:
Click here to enter the city name and state/province if applicable.
Country:
Click here to enter the country name.
Phone Number:
Email:
Click here to enter the phone number where this author can be reached.
Click here to enter the email address where this author can be reached.
Does the presenting author have any disclosures to make?
☐ No, the presenting author has no disclosures to make.
☐ Yes, the presenting author has the following disclosures to make.
Within the past 12 months, I and/or my spouse/significant other have received support from or had a relationship with the
following commercial interests. Disclosure should include relationships in any amount.
The ACCME defines a commercial interest as any entity producing, marketing, re-selling, or distributing health care goods or
services consumed by, or used on, patients, with the exception of nonprofit or government organizations and non-healthcare
related companies. Providers of clinical services directly to patients are not considered a commercial interest.
Please review the list of relationships requiring disclosure below and enter the names of any applicable commercial interests
in the area provided.
Speakers’ Bureau
Consultant/Advisor
Stock Ownership (not including stocks owned in a managed
portfolio)
Research Grant (where listed as primary investigator)
Employment Affiliation
Royalty/Patents
If applicable, click here to enter company names.
If applicable, click here to enter company names.
If applicable, click here to enter company names.
If applicable, click here to enter company names.
If applicable, click here to enter company names.
If applicable, click here to enter company names.
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Abstract Submission Form
Author Details – Co-Authors
Second Author
First Name: Click here to enter the author’s first name.
Last Name: Click here to enter the author’s last name.
Institution Name: Click here to enter the institution name.
City & State/Province: Click here to enter the city name and state/province if applicable.
Country: Click here to enter the country name.
Does the second author have any disclosures to make?
☐ No, the second author has no disclosures to make.
☐ Yes, the second author has the following disclosures to make.
Click here to enter company names along with relationship.
Third Author
First Name: Click here to enter the author’s first name.
Last Name: Click here to enter the author’s last name.
Institution Name: Click here to enter the institution name.
City & State/Province: Click here to enter the city name and state/province if applicable.
Country: Click here to enter the country name.
Does the third author have any disclosures to make?
☐ No, the third author has no disclosures to make.
☐ Yes, the third author has the following disclosures to make.
Click here to enter company names along with relationship.
Fourth Author
First Name: Click here to enter the author’s first name.
Last Name: Click here to enter the author’s last name.
Institution Name: Click here to enter the institution name.
City & State/Province: Click here to enter the city name and state/province if applicable.
Country: Click here to enter the country name.
Does the fourth author have any disclosures to make?
☐ No, the fourth author has no disclosures to make.
☐ Yes, the fourth author has the following disclosures to make.
Click here to enter company names along with relationship.
Fifth Author
First Name: Click here to enter the author’s first name.
Last Name: Click here to enter the author’s last name.
Institution Name: Click here to enter the institution name.
City & State/Province: Click here to enter the city name and state/province if applicable.
Country: Click here to enter the country name.
Does the fifth author have any disclosures to make?
☐ No, the fifth author has no disclosures to make.
☐ Yes, the fifth author has the following disclosures to make.
Click here to enter company names along with relationship.
Sixth Author
First Name: Click here to enter the author’s first name.
Last Name: Click here to enter the author’s last name.
Institution Name: Click here to enter the institution name.
City & State/Province: Click here to enter the city name and state/province if applicable.
Country: Click here to enter the country name.
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Abstract Submission Form
Does the sixth author have any disclosures to make?
☐ No, the sixth author has no disclosures to make.
☐ Yes, the sixth author has the following disclosures to make.
Click here to enter company names along with relationship.
Seventh Author
First Name: Click here to enter the author’s first name.
Last Name: Click here to enter the author’s last name.
Institution Name: Click here to enter the institution name.
City & State/Province: Click here to enter the city name and state/province if applicable.
Country: Click here to enter the country name.
Does the seventh author have any disclosures to make?
☐ No, the seventh author has no disclosures to make.
☐ Yes, the seventh author has the following disclosures to make.
Click here to enter company names along with relationship.
Eighth Author
First Name: Click here to enter the author’s first name.
Last Name: Click here to enter the author’s last name.
Institution Name: Click here to enter the institution name.
City & State/Province: Click here to enter the city name and state/province if applicable.
Country: Click here to enter the country name.
Does the eighth author have any disclosures to make?
☐ No, the eighth author has no disclosures to make.
☐ Yes, the eighth author has the following disclosures to make.
Click here to enter company names along with relationship.
Ninth Author
First Name: Click here to enter the author’s first name.
Last Name: Click here to enter the author’s last name.
Institution Name: Click here to enter the institution name.
City & State/Province: Click here to enter the city name and state/province if applicable.
Country: Click here to enter the country name.
Does the ninth author have any disclosures to make?
☐ No, the ninth author has no disclosures to make.
☐ Yes, the ninth author has the following disclosures to make.
Click here to enter company names along with relationship.
Tenth Author
First Name: Click here to enter the author’s first name.
Last Name: Click here to enter the author’s last name.
Institution Name: Click here to enter the institution name.
City & State/Province: Click here to enter the city name and state/province if applicable.
Country: Click here to enter the country name.
Does the tenth author have any disclosures to make?
☐ No, the tenth author has no disclosures to make.
☐ Yes, the tenth author has the following disclosures to make.
Click here to enter company names along with relationship.
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Abstract Submission Form
Abstract Content
Abstracts are limited to 500 words. Content should be structured into four sections:
Background:
Methods
Results:
Conclusion:
Click here to enter your abstract content.
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Abstract Submission Form
Tables/Graphics
The use of up to two (2) relevant tables and/or graphics is encouraged. Save your table/image as a picture file, and then select
the icon below to insert it into your submission form.
Table/Image 1: Click here to enter the name of your first table/image.
Click the icon to insert your first table/image here:
Table/Image 2: Click here to enter the name of your second table/image.
Click the icon to insert your second table/image here:
Submission Instructions
To submit your work for consideration, please send this completed form to [email protected] for receipt by 11:59 PM
Eastern Time on Sunday, November 16, 2014. Questions? Contact [email protected].
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