EMPoweRx Encore Submission Form

Name *

First

Last

Email *

Credentials: (e.g., PharmD, MD, PA-C, NP) *

Affiliation: (Name of Institution/Hospital/Company) *

Email Address: (for communication purposes) *

Professional Title: (e.g., Clinical Pharmacist, Emergency Medicine Physician, etc.) *

Social Media Profile: (optional)

LinkedIn Profile: Twitter Profile:

Biography

Phone

Presentation Title: (concise and descriptive) *

Presentation Abstract: (max 500 words) *

Key Takeaways: (List 3-5 key points the audience will learn from your presentation)

Research or Topic Keywords: (3-5 keywords, separated by commas)

Relevance to Emergency Medicine Pharmacotherapy: (explain the significance of your topic to the field) *

Have you presented this topic elsewhere?

I agree to have my presentation recorded and shared as part of the EMPoweRx Encore segment of the EMPoweRx conference: *

Additional Information

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