PHW Presentation Request Form

The following information is required when requesting a speaker for a virtual presentation (one form per presentation). Upon completion, PHW staff will send a confirmation email with further information.

Note: In response to COVID-19 pandemic, federal, state, and local laws, orders, and CDC guidance is regularly changing. Therefore, TMA reserves the right to cancel, reschedule, or change the format (e.g., make the presentation virtual) of a presentation without advanced notice.  

 Free CME presentations are available for learning health systems. For all other requests, payment is due one week before the presentation.

Contact Person:  
Title/Department:  
Entity/Organization (include branch)/Institution:  
Address:  
City:  
State:  
Zip:  
Telephone:  
Email:  
Select one topic:  
Date of presentation:     [None] Select a Date Delete the Date
Event type:  
Presentation start time:  
Presentation location:  
Address:  
City:  
State:  
Zip:  


Anything we need to know?      
   

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

Usage of TMA Committee on Physician Health and Wellness Copyrighted Materials, Cancellations, Disclaimer, Release and Indemnity Agreements

[By checking this box, you agree you are legally authorized to consent to this agreement on behalf of the above-named entity/organization. Also by checking this box, you agree to sign this document electronically, and that this checked box (and any checked box herein) constitutes your electronic signature. You agree your electronic signature has the same legal validity and effect as your handwritten signature on the document, and that it has the same meaning as your handwritten signature.

[ ] By checking this box, for an in-person presentation, if the above-named entity/organization cancels or reschedules while a speaker is traveling to or has already traveled to the city where the presentation is scheduled to occur, the above-named entity/organization agrees to pay the travel expenses incurred by the speaker (mileage and hotel (if applicable) only) in addition to the invoice fees.

[] By checking this box, during the COVID-19 outbreak, the above-named entity/organization agrees that during a live in-person presentation it (a) will not participate in a way that would violate any applicable local, state, and/or federal laws or orders, including those related to prohibitions or limitations on public gatherings; (b) will not permit attendees, employees, members, vendors and agents to participate in a way that would violate such laws or orders; and (c) will comply with CDC-issued guidance relating to COVID-19 and mandate that its attendees, employees, members, vendors and agents do the same.

[] By checking this box, the entity/organization acknowledges it will not record or film the presentation without express written permission from an authorized agent of TMA and, if such permission is granted, it will only use such recording or film as agreed to by and between TMA and the entity/organization. The entity/organization will also take reasonable efforts to prevent attendees from recording or filming the presentation, including notifying attendees that any recording or filming of the presentation is prohibited unless the entity/organization has express written permission from an authorized agent of TMA to permit such recording or filming by attendees.

 [ By checking this box, the entity/organization acknowledges, understands, and agrees to the disclaimer, release, and indemnity agreement located here.

      

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