16th Annual Mobile Health Clinics Conference Speaker Packet

Speaker Information

16th Annual Mobile Health Clinics Conference • Phoenix, Arizona
16th Annual Mobile Health Clinics Conference: Please fill out this form as completely as possible. This information will be used in the printed program, the mobile app, our speakers' web pages, news releases, and other material used to promote our speakers and the Conference.
Speaker Information Information:

Please enter information as you would like it to appear on the printed agenda & roster
Full Name:

First NameLast NameSuffix (MD, DDS, RN, NP, etc....)
Professional Title or Position: as you would like it to appear on printed materials
Institution/ University or Practice:
Address

Work Address

Work Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail
Office Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Office PhoneCell PhoneE-mail
My Office Contact Person (Optional)

First NameLast Name
Office Contact Person Phone

Area CodePhone Number
Office Contact Person Email
YesNo
Dietary restrictions to consider:

Speaker Bio and Optional Photo

Please upload you bio and optional head shot. Use the sample bio below as a reference for content and format.
Photo (500 or more pixels wide, optional)

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Bio Upload

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Please use this sample bio as a reference for content and layout

Presentation Information:

You must bring your PowerPoint presentation to your session along with a laptop or device that can connect to the AV provided. If you are unable to bring a laptop, arrangements must be made no later that August 31, 2020. It is the presenters responsibility to ensure that the presentations they provide are: - PROOF READ for grammatical content - Slide text font and size are clear and large enough to be read by the audience - Presentation slides support the summary and learning objectives of the original abstract submission.
I give permission to post this presentation on the Mobile Healthcare Association website
I consent to my presentation being recorded?
PCMACOther

Speaker Disclosure Forms

Please Complete ALL speaker disclosure forms
Speaker Disclosure Form - Medical
Speaker Disclosure Form Dental
Please Attach Completed Medical and Dental Forms (Both MUST be completed by each speaker)

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Speaker Information Information: