16th World Meeting on Sexual Medicine

Hotel Transamérica São Paulo, 8 to 12 October 2014

Conflict of Interest Disclosure Form

Please carefully ready and complete the disclosure form below.

Title of CME Activity: 16th World Meeting on Sexual Medicine
Activity Number/Date: 8 to 12 October 2014
Location of Activity: Sao Paulo, Brazil
1. CME Presenter/Author Name:

First Name

Last Name


2. Disclosing as:

1. Presenter (invited presentation or abstract presentation)       
2. Author (author or co-author of an accepted abstract)       
3. Presenter and Author (any combination of 1. and 2.)       
4. Moderator / Other (if you do not present and are not an author of an abstract)

Presenters: please complete questions 3+4+5, sign and date below.
Authors: please complete question 4A, sign and date below.
Moderators / Other: please complete question 4A, sign and date below.

(See glossary of terms for guidance)

By signing this document, I agree to the following elements as expected of individuals involved in the planning and implementation of accredited/certified educational activities.
Presenters must answer questions 3+4+5. Do not forget question 4B. Authors / Moderators / Other must answer Question 4A.

3. All CME speakers must read, agree, and check the all following statements. I will:

A. I or my spouse/partner presently (within the past 12 months) has relevant financial relationships with a commercial interest(s) as identified below:
[Please indicate the full name of the commercial interest(s)/organization(s) next to the best description of the relationship(s).]
B. Will your presentation(s) include discussion of any products or services from the above listed commercial interest(s)?
I will make clinical recommendations in this/these presentation(s).
By selecting "I Agree" I represent and acknowledge that:
  1. I have read, understood, and consented to electronic delivery of, the disclosures above.
  2. I intend the act of selecting "I Agree" to be my legal signature to this agreement.
Email address

Telephone Number

Date (Y-M-D)