Speaker Request

What is the name of your event?

Is your event medical or dental?

What topic would you like an MDDUS speaker to cover?

What is the date of your event?

Where is the event being held?

Please detail the length of the speaker slot available and include timings if known.

How many people do you expect to attend?

Please detail here the composition of the audience. (e.g. GP trainees, consultant psychiatrists, dental VTs, practice managers etc.)

What is the preferred format of the session? (e.g. lecture, workshop etc.)

Are you able to provide audio visual equipment? (e.g. laptop, data projection)

Equipment details if applicable

Are you able to offer reimbursement for reasonable travelling expenses?

Reimbursement details if applicable

Are you able to offer a speaker fee?

Fee details if applicable

Would you be agreeable to a marketing presence at your event?

Please provide your contact details here so we can get in touch about your request.

Title

Name

Telephone

Speaker request