Doximity Author Disclosure Form
Doximity welcomes members to submit their stories, experiences, and other content for publication on our platform. We believe it’s important to inform readers of our authors’ financial interests in the subject matter of their submitted content, so we require that this Author Disclosure Form be completed in connection with certain submissions. If you identify any relevant financial interests, we will include the relevant information along with your published submission.
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Email *
Your name *
Submission name *
Corresponding author
Enter N/A if not applicable
LICENSE GRANT *
You agree that by submitting content to us, you grant Doximity a nonexclusive, irrevocable, worldwide, perpetual, unlimited, assignable, sublicensable, royalty-free, fully-paid up license to use, copy, distribute, publish, display, prepare derivative works from, and commercialize such content in any media, form or format now known or hereafter developed, in any manner subject to applicable law. You also represent to us that you have all rights necessary to submit the content to us for use in accordance with this license and that no element of the submitted content infringes or violates the rights of any person or entity including, without limitation, intellectual property, publicity or privacy rights, or violates applicable laws, rules or regulations.                                                                                                                                                      *This license is not applicable if you have executed a separate agreement with Doximity in connection with the submitted content.
Required
CONFLICT OF INTEREST DISCLOSURES
A conflict of interest exists when professional judgment concerning a primary interest (such as patients’ welfare or the validity of research) may be influenced by a secondary interest (such as financial gain). This form is intended to help us understand if there could be any interest that presents a real or perceived conflict of interest or bias.

Please enter descriptive details if you have the financial interests identified below in the subject matter of your submission, or if you have any relationship with an entity that has financial interests identified below in the subject matter of your submission.
- Include information for entities with whom you have had a relationship in the last 24 months, or anticipate you will have in the next 6 months.  
- Include any such interests of your immediate family members.
- Enter N/A if not applicable.

I have no financial interests or conflicts of interest to report.
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Employment
Grant received/Grants pending
Consulting fees or honorarium
Support for travel to meetings for the study, content preparation, or other purposes
Fees for participation in review activities such as data monitoring boards, etc
Payment for writing or reviewing the content
Provision of writing assistance, medicines, equipment, or administrative support
Payment for lectures including service on speakers bureaus
Stock/Stock options
Expert testimony
Patents (planned, pending, or issued)
Royalties
Other (err on the side of full disclosure)
By hitting the “Submit” button below, I certify that I have fully read and fully understood this form, and that the information that I have presented here is accurate and complete to the best of my knowledge.
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