NCSPS Annual Scientific Meeting Disclosure
November 5-7, 2021

North Carolina Society of Plastic Surgeons (NCSPS)
6300 Sagewood Drive, Suite H255
Park City, UT 84098
P:(435) 200-8272 F:(435) 487-2011
E-mail:     Website:

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* 1. What is your First and Last Name?

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As a provider accredited by the Accreditation Council for Continuing Medical Education, we must ensure balance, independence, objectivity and scientific rigor in all of our sponsored educational activities. We adhere to the ACCME Standards for Commercial SupportSM. Your Role (Check all that apply)

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* 3. Everyone who is in a position to control the content of an educational activity throughout the planning and delivery phases must disclose to us any relationship with a commercial interest. A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. This definition exempts non-profit or government organizations; non-health care related companies; liability and health insurance providers; group medical practices; and for-profit hospitals, rehabilitation centers and nursing homes.

A conflict of interest exists when an individual (or their spouse/partner) has a financial relationship with a commercial interest and the opportunity to affect CME content related to that commercial interest. The intent of disclosure is not to disqualify a speaker, author or program planner from participating in an educational activity, but to resolve any potential conflicts of interest that may arise from financial relationships with a commercial interest that are determined to be relevant. The Aesthetic Society has a process to resolve any conflicts of interest and assumes that resolution will be possible. During this process, you may be asked for further information or explanations.


Please complete this disclosure statement and sign upon completion. If you are unable to disclose these financial relationships for any reason, you will be disqualified from participating in the planning or delivery of this activity.

Please list any financial relationships with a commercial interest.

Please note the following:

1. ACCME policy requires that relationships of the person involved in the CME activity.

2. There is no set minimum dollar amount for these financial relationships and they must be disclosed if they occurred within the past 12 months (use date of activity as reference point).

3. The nature of the relationship and the name of the commercial interest must be noted in the disclosure. However, indicating a financial amount is not necessary.

4. Prior to the start of the activity, your financial relationships or lack thereof will be disclosed to the audience.

Nature of Financial Relationship (If you need additional space to disclose, please contact the Society office by e-mail at or phone 435-200-8272.

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Faculty members and others are also requested to refrain entirely from any references to unapproved or “off-label” use of medications or devices as to which a disclosure has been made. All faculty/participants shall be informed that if any unapproved or “off-label” use of a product is to be referenced in a CME program presentation, the faculty member/participant shall be required to disclose that the product is either investigational or that it is not labeled for the usage being discussed. Any faculty member/participant who either fails to fully disclose relevant relationships with a commercial entity, or who violates the prohibition on discussion of the related unapproved or “off-label” usage, shall be precluded from consideration for future presentations at The Aesthetic Society CME events/programs. The Aesthetic Society shall convey any information disclosed by the faculty member/participant to the CME program audience by:

The Aesthetic Society expects that all of its CME programs will adhere to the ACCME’s validation statements. Specifically, all the recommendations involving clinical medicine in a CME activity must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients or otherwise be noted as personal opinion based on clinical experience. All scientific research referred to, reported, or used in CME in support of justification of a patient care recommendation must conform to the generally accepted standards of experimental design, data collection and analysis. Please contact NCSPS if you do not feel your presentation can meet these Standards.

I acknowledge that I have read and considered the content listed above. I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional circumstances might reasonably be expected to affect my views on the subject on which I am presenting, except those as indicated on the following page.

1. I understand and will ensure that my presentation will adhere to the ACCME’s content validation statements.
2. I understand that my presentation is to contain no mention of any products or services offered to which I have any direct or indirect connection which I have not disclosed in this conflict of interest statement.
3. I understand that my presentation is to contain no mention of any unapproved or “off-label” use of medications or devices which have not been disclosed here.
4. I certify that all photographic material presented is done with the appropriate medical/patient releases for photography and subsequent use in presentations.
5. I certify that all printed material presented is done with the permission of the author, and that my use of such materials will not violate copyright laws.

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6. I will promptly disclose any actual or apparent conflicts of interest that may arise after I sign this form, but before I give my presentation.
7. I understand that no advertising or promotion of any products or services (including authored books, videos, DVD’s or other printed or electronic media) will take place during my presentation or in the space where this CME activity is provided.
8. I understand that The Aesthetic Society is not responsible for the content of my presentation, and I accept full responsibility for the presentation of appropriate and ethical material.
9. I agree that I will not accept payment from a commercial interest for my role as presenter/faculty/planner in this activity.