Society to Improve Diagnosis in Medicine


Speakers Bureau Request Form
In order for us to best accommodate your request, please submit the completed form as early as possible, with six weeks as the preferred minimum.
Topic Area
If Other, please specify.
If requesting a specific speaker, please enter their name.
Your Information
First Name *
Last Name *
Email *
Phone *
Company Name *
Event Information
Type of Event
Event Title
Speaking Date
Audience Size
Presentation Format
Venue City
Venue State (Providence/Region/Country if outside USA)
Date by which you request a confirmation
Will your event be accredited (e.g. CME, CNE, CEU)?	Yes No
If yes, who is the accredited provider?
Will you cover travel expenses?	Yes No
Will you provide an honorarium?	Yes No
Additional Information
Privacy Policy for Society to Improve Diagnosis in Medicine
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Speakers Bureau Request Form