2023 IADR/LAR General Session with WCPD - Abstract Withdraw, Presenter Change, and Refund Request Form Are you an Abstract Presenter? Yes No Current Presenter Full Name: First Name Last Name Abstract ID#: Email: Select Requested Action Presenter Change Withdraw Neither Replacement Presenter Full Name: First Name Last Name Replacement Presenter Email: Replacement Presenter Phone Number: For Student Replacements please select category: - None -College, University, pre-Dental, or Secondary StudentDDS/DMD or BDSMD or DO StudentsMasters Student with no professional degreeMasters Student after professional degreePhD Student with no professional degreePhD Student after professional degreeDual Degree Program StudentPost-Doctoral (Dental or Medical Fellow and PhDOtherNOT A STUDENT FOR THE REPLACEMENT PRESENTER ONLY: Please confirm the following information: Does the replacement presenter have a significant financial interest/arrangement or affiliation with an organization/institution whose products or services are being discussed in this session. This information must be disclosed to the participants who attend my presentation. Yes No If the answer to the above is Yes, please provide the organization/institution name and speaker relationship to the organization/institution. Reason for withdraw/presenter change: Your Details Full Name Email Do you need to request refund/cancel your registration? Please note registration cancellations will be considered based on the deadline dates outlined in the meeting refund policy located on the meeting page Yes No Registration ID:? Reason for registration cancellation/refund: Based on your selections, there is no need for you to submit this form. If you intend to change your abstract or cancel your registration please review your above selections before submission. Based on your selections, there is no need for you to submit this form. If you intend to change your abstract or cancel your registration, please review your above selections before submission.
