IIRRM Congress Faculty Form | The International Clinical & Scientific Congress for Restorative Reproductive Medicine

2026 International Clinical & Scientific Congress for RRM

Faculty Form

Orlando, Florida, USA – October 7 – 10, 2026

Thank you for agreeing to present, or serve as a discussant, for our 22nd International Conference for Restorative Reproductive Medicine, hosted in Orlando, Florida, on October 9-10 with pre-conferences hosted on October 7-8. For the purposes of providing unbiased CME, and in accordance with IIRRM’s Speaker Policy, all declarations of potential or actual conflicts of interest must be provided. The existence of potential conflicts of interest does not necessarily indicate a bias.

Additionally, in accordance with EACCME® Accreditation of Live Educational Events (LEEs), declarations must include whether any fee, honorarium, or arrangement for reimbursement of expenses in relation to the conference has been provided.

If you have any questions, please don’t hesitate to email us at: secretariat@iirrm.org.

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Full Name *

Degrees or professional affiliations and designations *

Email *

Phone Number *

Please select all that apply: *

Speaker
Abstract Presenter (Oral)
Abstract Presenter (Poster)
Part of the Scientific Organizing Committee
IIRRM Board Trustee

Title of Presentation(s): *

Please indicate if you serve in any of the following positions as a trustee or a board member, either appointed in full or serving as in-term until the position is filled

President
Treasurer
Vice-President
Secretary
Other

You indicated you serve in another executive role as a trustee or board member. Please enter this role above.

Do you or does any member of your immediate family have a financial relationship or interest with any proprietary entity producing health care goods or services? *

Please check the relationship below:

Research Grants
Speaking or Presenting
Ownership
Consultant for fee
Employment
Partnership
Stock/ Shareholder/ Bond Holdings (excluding mutual funds)
Other: Please describe in the space provided below

Please indicate the names of all organizations in which you have a financial relationship or interest and the specific clinical areas that correspond to the relationship.

If not already reported above, please select if you are in receipt of any of the following, or have any other potential conflict(s) of interest to report:

Receipt of grants/research supports
Receipt of conference honoraria or speaker stipend
Participation and/or employed in a company sponsored speaker’s bureau
Other support

Please specify, and if applicable, state the name of the commercial company:

Have you receive an honorarium, consulting fee, or any other type of compensation from a proprietary entity producing health goods or services that relate to the topic of your presentation? *

Have you participated in any speaker training related to your topic? *

Will your presentation include slides or printed materials provided by a proprietary entity? *

The content of my material(s)/presentation(s) in this CME activity will include discussion of unapproved or investigational uses of pharmacological, biological, and medical products or devices. This includes the off-label use of pharmacological drugs. *

If the answer to any of the questions 2-5 is “yes,” please provide pertinent details below.

Please list 2-5 learning outcomes that attendees will gain from your presentation ? *

For an explanation and examples of developing learning outcomes for CME please view this link: http://iirrm.org/learning-outcomes/.

Please provide 2-4 references supporting your presentation

This is required for our accreditation through the EACCME. You can also email your references to kathleen@iirrm.org at a later time. We do not need an entire list of all referenes you plan to use in your presentation, 2-4 peer-reviewed scientific articles supporting the general topic or background is sufficient.

I give permission for my presentation to be video recorded and posted on the conference website for educational purposes. Access to the recording will be restricted through a protected/paywalled platform for registered Congress attendees. *

Yes
No
Yes, with conditions

Please note conditions or concerns below

I acknowledge that I retain copyright in the text, graphics, and other materials contained within my presentation. I consent to IIRRM distributing the PDF slide handout and recorded presentation only to individuals registered for the Congress, including those attending live or accessing the protected post-event recording portal. I understand that access will be restricted through a protected/paywalled platform for Congress registrants to review the material. IIRRM will not sell, license, republish, or use my presentation materials for any other purpose without my prior written permission. *

Yes
No
Yes, with conditions

Please note conditions, concerns or restrictions of use/distribution below

I have answered these questions to the best of my knowledge. If I have a financial relationship or interest, I understand that this information will be reviewed to determine whether a conflict of interest may exist, and I may be asked to provide additional information. I understand that failure or refusal to disclose, false disclosure, or inability to resolve conflicts of interest will require the conference comittee to identify a replacement.

Clear Signature

By signing above, I acknowledge and agree to the above terms of acceptance.

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