The Houston Aortic Symposium 2024 March 21, 22 & 23, 2024Houston, Texas Abstract Presentation Acceptance & Financial Relationships FormYour Name*Enter your full name exactly as it should appear in the meeting materials. First Last Are you available to participate as an abstract presenter in the Houston Aortic Symposium 2024?* Yes, I agree to participate as an abstract presenter (oral and/or electronic poster depending on the details in my acceptance email) No, I cannot participate as an abstract presenter Email*Enter the email where you would like to receive future meeting correspondence. Enter Email Confirm Email Degrees/Credentials*Enter the degrees/credentials you would like to appear in the meeting materials. Salutation*Choose Your SalutationDr.Mr.Ms.Prof.Hospital / Affiliation* Physical Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone Number*Phone Type*Choose phone typeMobileOfficeHomeFax Number As a prospective participant, we would like to ask for your help in protecting our learning environment from industry influence. Please complete the form below and click "Submit Form" when you reach the end. The ACCME Standards for Integrity and Independence require that we disqualify individuals who refuse to provide this information from involvement in the planning and implementation of accredited continuing education. Thank you for your diligence and assistance. If you have questions, please contact us at [email protected].Prospective role(s) in this activity* Speaker Instructions for this form 1) Please disclose all financial relationships that you have had in the past 24 months with ineligible companies. An ineligible company is any entity whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. More information here. 2) For each financial relationship, enter the name of the ineligible company and the nature of the financial relationship(s ). There is no minimum financial threshold; we ask that you disclose all financial relationships, regardless of the amount, with ineligible companies. You should disclose all financial relationships regardless of the potential relevance of each relationship to the education.Examples of financial relationships include employee, researcher, consultant, advisor, speaker, independent contractor (including contracted research), royalties or patent beneficiary, executive role, and ownership interest. Individual stocks and stock options should be disclosed; diversified mutual funds do not need to be disclosed. Research funding from ineligible companies should be disclosed by the principal or named investigator even if that individual's institution receives the research grant and manages the funds. 3) If the financial relationship existed during the last 24 months, but has now ended, please indicate in the field provided. This will help the education staff determine if any mitigation steps need to be taken.Relationships Declaration* In the past 24 months, I have had financial relationships with ineligible companies. In the past 24 months, I have not had any financial relationships with any ineligible companies. Financial Relationships*To add additional relationships, click the plus button on the right-hand side.Name of Ineligible CompanyNature of Financial RelationshipHas this relationship ended? Enter Yes or No Consent* I attest that the above information is correct as of this date of submission .Date Completed* MM slash DD slash YYYY Release FormsThe Houston Aortic Symposium 2024, taking place March 21-23, 2024, may videotape, audiotape, and/or reproduce portions of the symposium for the purpose of reference and/or teaching in an online format. Additionally, faculty slides for the The Houston Aortic Symposium 2024 will be made available online in PDF format for attendees to access after the symposium in the online meeting syllabus. Please review, complete, and submit the form below.Permission for your presentation slides and/or abstract text to be shared with attendees in the online syllabus as a PDF* YES, I give my permission to share my slides and/or abstract text as a PDF online with meeting attendees NO, I do not give my permission to share my slides and/or abstract text as a PDF online with meeting attendees Permission for your participation to be video and/or audio taped*By choosing "YES" below, I authorize The Houston Aortic Symposium 2024 to videotape and audiotape my complete presentations(s) and consent to allow the use and reproduction of my name, presentation(s), and all materials contained in my presentation(s). My videotaped and audiotaped presentation(s) and materials will only be used, reproduced and distributed within the context of the conference program. To the best of my knowledge, use, and reproduction of the materials or information used in my presentation(s) will not violate any third party’s copyrights or other property rights. To the extent copyrighted or trade secret materials are used, reproduced or displayed with my presentation(s), I have obtained written permission to use, reproduce, and distribute such materials from the copyright owner. YES, I give my permission for my presentation(s) to be videotaped and/or audiotaped NO, I do not give my permission for my presentation(s) to be videotaped and/or audiotaped Please click "submit form" below to submit your decline to participate.Thank you for completing your faculty paperwork! You will receive a copy of this form for your records via email within 3 business days. Please click "Submit" below to finalize.NameThis field is for validation purposes and should be left unchanged.