Annual Concierge Medicine Forum, National Industry Conference: Speaker Application
Call For Conference Speaker Submissions Topics and Faculty for Our October Conference | Deadline April 1 @ Midnight ET.
Full Name (of Speaker Applicant)
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Last Name
Name of Your Organization
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2026 Concierge Medicine Forum, National Industry Conference: Speaker Application
Call For Conference Speaker Submissions Topics and Faculty for Our October Conference | Deadline April 1 @ Midnight ET.
Office Mailing Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Office Phone Number
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Format: (000) 000-0000.
Permission to Share Email With Attendees, Event Participants and Sponsors
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E-mail Address
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Company/Business Web Site Address
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Tell Us About Your Presentation
What presentation format will you be submitting for? Select all that may apply to your content.
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Pre-Conference Workshop
General Session
Breakout Session
Sponsorship
Keynote Presentation
Type of Entity You Are From: (e.g. Business or University)
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Job Title/Your Position
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Have you previously attended or Spoken at the Concierge Medicine Forum?
Please Select
Yes
No
It is okay if you have, we just like to know if this is your first time. Thank you.
Title of Possible Presentation
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Presentation Description
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Brief description of presentation. Two to three sentences is fine.
Key Learning Objectives
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A few bullet points here is acceptable. Thank you!
Why do you believe this presentation would be of benefit to the Doctors in attendance?
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Two to three sentences is fine.
If you have any supporting materials such as a previous presentation, white paper, published article etc., please upload here. PLEASE NOTE: .ppt files will not upload. Please convert and submit as a .pdf file.
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Browse Files
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Choose a file
Photo Release and Disclaimer: If you upload a headshot or two in this space, please be aware, by attaching a headshot to this Application, if selected, this is the headshot/photo that may be used and it is understood that you have full rights and permission to use the photo(s). Therefore, you are recognizing that you are the owner of the photo(s) and are authorizing Concierge Medicine Today, LLC., (herein "CMT)" to use for marketing purposes for this event. You grant your permission for CMT to use the photo(s) for marketing purposes for this event. You understand that you, the owner, are responsible for any royalties or copyright fees as a result of its use. Additional Terms and Conditions are listed in the "Speaker Agreement" (linked above).
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If chosen, will the Speaker be traveling with any additional guests or a spouse? If yes, additional passes beyond the total of (1) will need to be purchased separately.
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How many additional tickets will you need, if accepted as a Speaker? Please note, all participants are subject to "Conference Participant Terms and Conditions."
Yes
No
Please note, only a total of two "Complementary All-Access 2.5 Day Passes" (which includes the Speaker) are provided to the Speaker and his/her guest. Acceptance of Speaker and Participant Terms and Conditions apply. . As a Speaker benefit, Speakers are invited to and welcome to attend ALL public Conference breakouts/sessions, exhibit hall, panel discussions and one pre-conference workshop for free/at no added registration cost. Concierge Medicine Today, LLC., is the industry trade publication and host of the industry’s annual medical education conference. The Concierge Medicine Forum (CMF), provides medical education teaching, instructional workshops and industry education experiences for Physicians and healthcare professionals in attendance at this live conference. Our educational and conference activities showcase the industry’s subscription-based healthcare delivery models and support networking and connections within the healthcare community at-large.
Is the contact information for the Speaker the same as the primary contact information entered above? If no, please provide contact information in the space below.
Please Select
Yes
No
Contact Information, if different from what is listed above.
If chosen, what size pullover/hoodie/sweatshirt are you?
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If you like an “oversized” hoodie, please choose one size up.
Adult Small
Adult Medium
Adult Large
Adult XL
If you like an “oversized” hoodie, please choose one size up.
Acceptance of Speaker and Participant T&Cs and Speaker Agreement.
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Yes, I understand that is selected as a Speaker, I (and all in my party) are 100% Responsible For all Costs and Expenses. No Honorarium Will be Provided.
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Please Select
Yes, I understand and accept these Terms and Conditions.
This conference supports the operations of the industry trade publication throughout the year to help support this space. CMF does not provide an honorarium or reimburse speakers for travel or other expenses. Speaker is 100% responsible for all costs and expenses associated with participating in any capacity at this Conference/events. Speaker will NOT be issued a travel stipend. Speaker is responsible for all of their travel and lodging arrangements to and from the CMT event(s). CMT does not reimburse, nor cover expenses related to your travel, hotel, or any other transportation or incidental expenses incurred by the Speaker while participating in any CMT Conference.
How did you learn about us?
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Email
Internet Search
Someone Referred Me
Avid Reader of Your Publication(s)
Social Media
News Magazine Story
Would You or Your Company Be Interested In Sponsorship/Branding Opportunities?
Please Select
Yes
No
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