Presenter Logistics Information Form

For all those who will be attending and working the TOXINS 2022 6th International Conference, all attendees must be fully vaccinated, and show proof of vaccination upon arrival on site in New Orleans in order to attend the conference.

COVID-19 Vaccination Status*

Yes, I am fully vaccinated or will be before the conference.
No, I’m not vaccinated.

On June 11, 2021, The American Medical Association released the results of a survey of practicing physicians that shows that more than 96 percent of surveyed U.S. physicians have been fully vaccinated for COVID-19, with no significant difference in vaccination rates across regions¹. However, due to the current trend in new COVID-19 cases, and in the interest of protecting the health and safety of all those who will be attending and working the TOXINS 2022 6th International Conference, we are asking that all attendees be fully vaccinated, and show proof of vaccination upon arrival on site in New Orleans. For more information, please contact Rose Puleo at info@neurotoxins.org.

¹American Medical Association. Physician COVID-19 Vaccination Study (Final Report). June 2021.

Printed Materials

(This information will appear on all printed materials)

Username

First Name*

Last Name*

Degree

MD
PhD

Title*

Specialty*

Other Specialty*

Subspecialty

Affiliation*

Address 1*

Address 2

City*

State / Province / Region*

ZIP / Postal Code*

Country*

Personal Information for Hotel

Full Name*

(As it appears on your identification)

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Passport Number

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Passport Country of Issue

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Passport Expiration Date

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Date of Birth

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Nationality

Email*

Phone*

(Please include country code if applicable)

Cell Phone*

(Please include country code if applicable)

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship?

Spouse
Parent
Child

Will you bring a guest?*

No
Yes

Relationship?*

Spouse
Child

Guest Full Name*

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Pharmaceutical Employee

I am a Pharmaceutical Representative and not entitled to complimentary hotel accommodations.

Pharmaceutical Representative*

I am not a Pharmaceutical Representative.
I am a Pharmaceutical Representative and not entitled to complimentary hotel accommodations.

Hotel Information

Room Preference

Single
Double

Hotel Arrival Date

Hotel Time of Arrival

Hotel Departure Date

Number of Nights

Special Requirements, Allergies

Extended Stay*

No
Yes

Credit Card Number*

Expiration Month*

Expiration Year*

Security Code*

Cardholder Name*

Address*

City*

State / Province / Region*

ZIP / Postal Code*

Country*

Flight Information

If booking travel on your own, please send itinerary once flights are booked to Rose Puleo at rose.puleo@neurotoxins.org. (Itinerary and receipts must be submitted in order to receive reimbursement)

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New Orleans Arrival Date

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New Orleans Departure Date

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Travel

INA will book my travel
Book my travel on own

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Seat Preference

Aisle
Middle
Window

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Frequent Flyer Number

Preferred Flight

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City of Departure

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Arrival Airline

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Arrival Flight Number

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Departure Airline

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Departure Flight Number

Second Choice

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City of Departure

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Arrival Airline

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Arrival Flight Number

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Departure Airline

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Departure Flight Number

Printed Materials

Personal Information for Hotel

Hotel Information

Flight Information

Preferred Flight

Second Choice

Member Login

TOXINS 2022

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