Abstract Submission – wcpag 2023 abstract submission

Abstract Submission Form

Name of presenting author: *

E-mail of presenting author: *

Mobile phone:

Affiliation of presenting author:

PRESENTATION TYPESPOSTER ORAL VIDEO ANIMATION *Whilst every effort will be made to accept an abstract for the presentation type selected in the submission process, the Committee reserves the right to allocate a different presentation type if more appropriate and if program space is limited.

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Names of co-authors:

E-mails of co-authors:

Affiliations of co-authors:

Topic:

The full title of your abstract: *

Key words (not more then 5): *

Body of your abstract must not exceed 400 words for Original Study or 200 words for Case report

References: *

Tables and Figure:

DISCLOSURE OF INTEREST FORM

Note: In the interest of transparency, we ask you to disclose all relationships/activities/interests that are
related to the content of your manuscript. “Related” means any relation with for-profit or not-for-profit third
parties whose interests may be affected by the content of the manuscript. Disclosure represents a
commitment to transparency and does not necessarily indicate a bias. If you are in doubt about whether to
list a relationship/activity/interest, it is preferable that you do so.
The author’s relationships/activities/interests should be defined broadly. For example, if your manuscript
pertains to the epidemiology of hypertension, you should declare all relationships with manufacturers of
antihypertensive medication, even if that medication is not mentioned in the manuscript.

Date:

Name:

Institution:

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Please describe below any relationships, transactions, positions you hold, or circumstances that you believe could contribute to a conflict of interest:

I have no conflict of interest to report.

I have the following conflict of interest to report

I have the following conflict of interest to report* All support for the present manuscript (e.g., funding, provision of study materials, medical writing, article processing charges, etc.)
* Grants or contracts from any entity
* Royalties or licenses
* Consulting fees
* Payment or honoraria for lectures, presentations, manuscript writing or educational events, for expert testimony
* Support for attending meetings and/or travel
* Participation on a Data Safety Monitoring Board or Advisory Board
* Leadership or fiduciary role in other board, society, committee or advocacy group, paid or unpaid
* Stock options
* Receipt of equipment, materials, drugs, medical writing, gifts or other services
* Other financial or non-financial interests

During the development and/or presentation of content, I attest to the following:

a) The content and/or the delivery of information in my presentation will promote improvement and quality in healthcare, and will not promote a specific proprietary business interest of a commercial organization.YesNo

b) Recommendations involving clinical medicine discussed in my presentation will be based on evidence that is accepted within the profession of medicine that adequately justifies the indications and contraindications in the care of patients.YesNo

c) Scientific research referred to, reported or used in my presentation in support or justification of a patient care recommendation conforms to generally accepted standards of experimental design, data collection and analysis.YesNo

d) Research findings and therapeutic recommendations discussed in my presentation will be based on scientifically accurate, up-to-date information and presented in a balanced, objective manner.YesNo

Please check next to the following statement to indicate your agreement:

I hereby certify that the information set forth above is true and complete to the best of my knowledge.