TEMPLATE - POSTER ABSTRACT APPLICATION FORM

Vancouver 2012Poster Abstract Application FormName of Presenter: ____________________________________________________________Address: _____________________________________________________________________Postal Code: ___________ City: ____________________ Province: _________________Phone: ( ___ ) __________ Fax: ( ___) _______________ Email: ____________________Title of Poster: _______________________________________________________________Disclosure required. Is this poster presentation:Sponsored by Industry? Yes No_____________________________Abstract: Please submit a double spaced, typed abstract of no more than 300 words. Use TimesNew Roman, size 12 font. All clinical presentations should include case history, clinical situation,care provided, actions taken, results and outcomes, and implications for future practice.A completed Disclosure Form must be submitted with the abstract (see below).At least one author from an accepted must attend the conference in order for the poster to bedisplayed.Please submit this completed form, the abstract and the disclosure form by February 29 th , 2012to:Eleanore Howard, Poster Chair via email at: ehoward@avdha.nshealth.ca or by FAX to (902)542-4619.

Disclosure Statement for Poster PresenterDisclosure StatementI, , hereby disclose that I have the following potential conflict(s) of interest:I have received sponsorship from (indicate Industry name): __________________________I am employed by Industry (name): _____________________________________________I have received an honorarium/fee from Industry associated with this poster (industryname): ______________________________________________________________________This poster has not been presented at any other conference.This poster has been presented before at the following conference(s): (Name ofconference and date) ________________________________________________________Please disclose any other potential conflict of interests: __________________________________________________________________________________________________________________________________________________________________________________________________Signature: ____________________________________ Date: ____________________________Please submit the completed form to Eleanore Howard, Poster Chair via email at:ehoward@avdha.nshealth.ca or by FAX to (902) 542-4619.