Live PHW Presentation Request Form

The following information is required when requesting a speaker for a presentation (one form per presentation). Upon completion, PHW staff will send a confirmation email with further information. It is the requestor’s responsibility to provide the following audiovisual equipment for all presentations: LCD projector, laptop, podium, and microphone.

Full payment is due one week before the presentation.

Contact Person:  
Title/Department:  
Entity/Organization (include branch):  
Address:  
City:  
State:  
Zip:  
Telephone:  
Email:  
Select one topic:  
Date of presentation:   
Presentation location:  
Street address:  
City:  
State:  
Zip:  
Presentation start time:  
Number of medical staff onsite:  


Anything we need to know?      
   

Full payment is due one week before the presentation.

Questions?  Email phw[at]texmed[dot]org

Usage of TMA Committee on Physician Health and Wellness Copyrighted Materials

[] The above named entity/organization agrees not to use slides and materials developed for the Texas Medical Association Committee on Physician Health and Wellness (PHW) (as, by their publication, they are TMA copyrighted materials) for any presentations given for non-TMA-related activities without the express written permission of TMA.  Entity further agrees not to utilize documents of the PHW to prepare materials for other entities without the express written permission of TMA.  Entity also agrees not to record, live stream or distribute a recording of, PHW presentations without the express written permission of TMA.  

[] Canceled live presentations -- If the speaker has already traveled, the above named entity/organization agrees to pay the travel expenses incurred by the speaker (mileage only) in addition to the invoice fees.

      

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