CME Registration & Payment

PARTICIPANT INFORMATION

Full Legal Name

First Name

Last Name

Professional Designation Professional Designation

Primary Specialty

Medical License Number

State(s) of Licensure

Phone

Practice / Organization Name

City / State / Country

CME FORMAT & DATES

CME Dates (Confirmed)

May 29-31, 2026

CME Format

Live In-Person

Virtual

DISCLOSURE & COMPLIANCE

Please acknowledge the following:

This CME activity is educational only and does not provide medical advice or treatment recommendations.

No guarantees of outcomes are expressed or implied.

Content may include discussion of emerging research or off-label concepts for educational purposes.

I agree to practice within my licensed scope and jurisdiction.

CME participation does not confer certification, endorsement, or procedural authorization.

FACULTY DISCLOSURE (IF APPLICABLE)

Are you participating as faculty, speaker, or panelist?

Yes

(If yes) Do you have any relevant financial relationships to disclose?

Yes

(If yes) Please describe

MEDIA & RECORDING ACKNOWLEDGMENT

Please check

I acknowledge that CME sessions may be recorded for educational documentation.

I understand that separate written consent is required for promotional or commercial media use.

CERTIFICATION & ATTESTATION

By submitting this form and completing payment, I certify that:

All information provided is accurate
I am eligible for CME participation
I agree to all disclosures and policies above

Signature (typed in)

Clear

Date

CME REGISTRATION TYPE & PRICING

Select CME Registration Option (In-Person)

Select CME Registration Option (Virtual)

Total

Payment

Billing Address

City

State/Province

Zip/Postal

If you are human, leave this field blank.

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CONTINUING MEDICAL EDUCATION (CME) REGISTRATION & PAYMENT