Journal CME Conflict of Interest: Disclosure and Attestation
Lead Author:
     
Article:
     
Date:
     
The purpose of this form is to identify all potential conflicts of interests that arise from financial relationships between any author for this article and any commercial or proprietary entity that produces healthcare-related products and/or services relevant to the content of the article.  This includes any financial relationship within the last twelve months, as well as known financial relationships of authors’ spouse or partner.  The lead author is responsible for submitting the disclosures of all listed authors, and must sign this form at the bottom.  Additional forms may be submitted if the number of authors exceeds the space provided.
Lead Author:     
Email Address*:     
No financial relationships with a commercial entity producing health-care related products and/or services relevant to this article.
Company
Type of Relationship**
Content Area (if applicable)
     
     
     
     
     
     
     
     
     
Author:     
Email Address*:     
No financial relationships with a commercial entity producing health-care related products and/or services relevant to this article.
Company
Type of Relationship**
Content Area (if applicable)
     
     
     
     
     
     
     
     
     
Author:     
Email Address*:     
No financial relationships with a commercial entity producing health-care related products and/or services relevant to this article.
Company
Type of Relationship**
Content Area (if applicable)
     
     
     
     
     
     
     
     
     
Author:     
Email Address*:     
No financial relationships with a commercial entity producing health-care related products and/or services relevant to this article.
Company
Type of Relationship**
Content Area (if applicable)
     
     
     
     
     
submitting
     
     
     
     
Author:     
Email Address*:     
No financial relationships with a commercial entity producing health-care related products and/or services relevant to this article.
Company
Type of Relationship**
Content Area (if applicable)
     
     
     
     
     
     
     
     
     
Author:     
Email Address*:     
No financial relationships with a commercial entity producing health-care related products and/or services relevant to this article.
Company
Type of Relationship**
Content Area (if applicable)
     
     
     
     
     
     
     
     
     
Author:     
Email Address*:     
No financial relationships with a commercial entity producing health-care related products and/or services relevant to this article.
Company
Type of Relationship**
Content Area (if applicable)
     
     
     
     
     
     
     
     
     
Author:     
Email Address*:     
No financial relationships with a commercial entity producing health-care related products and/or services relevant to this article.
Company
Type of Relationship**
Content Area (if applicable)
     
     
     
     
     
     
     
     
     
Author:     
Email Address*:     
No financial relationships with a commercial entity producing health-care related products and/or services relevant to this article.
Company
Type of Relationship**
Content Area (if applicable)
     
     
     
     
     
     
     
     
     
As lead author of this article, I attest that I have received disclosure information from all participating authors as listed above, and have submitted the information completely and accurately as it was reported to me.  I understand that typing my name below serves as an electronic signature for the purposes of this form.
     
Type Name (Electronic Signature)

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