Conflict of Interest Disclosure Form
for Medical Professionals

Name Position/Title Department/Organization Email Date Do you or an immediate family member have any financial relationships (e.g., grants, employment, stock ownership, honoraria, paid expert testimony) with relevant organizations? Yes No If yes, please specify: Do you have any non-financial relationships (e.g., personal, professional, or voluntary positions) that may influence your work? Yes No If yes, please specify: Are there any other potential conflicts of interest to disclose? Yes No If yes, please specify: I hereby declare that the information provided above is accurate and complete to the best of my knowledge.