1MAJ
בישראל ו73vUS/ SSOCIATION LUOULL רות הרפואית ל
Full Disclosure form
Title of the article
Disclosure of financial relationships within 12 months of the date of this form and within the foreseeable future
A. Neither I nor any immediate family member (parent, sibling, spouse or child) has a financial relationship with or interest in any commercial entity that may have a direct interest in the subject matter of this article.
B. I have or an immediate family member (parent, sibling, spouse or child) has a financial relationship or interest with a commercial entity that may have a direct interest in the subject matter of this article.
| Name of author (all authors should sign) | signature | Please circle with reference to the above | Specify the relationship |
|---|---|---|---|
| A/ B | |||
| A/ B | |||
| A/ B | |||
| A/ B | |||
| A/ B | |||
| A /B | |||
| A /B |
Please indicate in the abstract of your article the disclosure.
Please send this signed form to fax no’ 972-3-7519673