Lifestyle Medicine 2018

Brisbane, 18th - 19th August 2017

Abstract & Scholarship Submission Form

(Please complete the Word document version of this form available from

Presenting author

Title: / First Name: / Surname:
Address for correspondence:
Suburb/City: / State: / Postcode: / Country:
Phone: / Fax: / Mobile: / Email:


Full title of abstract/work:
Additional authors (if any):
0 I am submitting an abstract, or 0 I am submitting a piece of work suitable for publication
If submitting an abstract, my preference is for: 0 Oral presentation
0 Oral and Poster presentation
0 Poster presentation
(tick one)

Student Scholarship

0 I wish to be considered for a student scholarship
University or Institute:
Award/course being undertaken:
0 Full-time, or 0 Part-time

Declarations of original work, ethics, informed consent, conflict of interest and sources of funding

To be considered for an abstract presentation or a student scholarship, the following declarations must be provided by you, and on behalf of your co authors (if applicable):

0 I declare that this research/work is my/our original work and consent to publication in the official conference proceedings and related publications.

0 I declare that if the research/work involves humans and/or animals, approval from an appropriate institutional ethics committee and informed consent from participants has been obtained in accordance with the NH&MRC statement on human experimentation and the NH&MRC/CSIRO/AAC Code of Practice for the Care and Use of Animals for Experimental Purposes

Any potential conflict of interest, and any sources of funding of a conference presenter must be disclosed. A potentail conflict of interest is defined as having a financial interest in a product or service discussed directly or indirectly in the presentation, being or having been an employee of a company with such financial interest, and/or receiving financial or in-kind support provided by an organisation/company related to a product or service discussed directly or indirectly in the presentation. Abstracts will not be considered for presentation unless this declaration of interest has been completed.

0 I declare the following potential conflicts of interest, and any sources of funding, on behalf of myself and my co-authors, as follows:




Confirmation of receipt

Please submit this form along with your abstract or work to . Full instructions are available at Please do not assume your email has been received unless you receive a reply email from us to confirm receipt within three working days.