ECHO Registration Form

If you plan to participate in the Show-Me ECHO, please complete the online form below.

* ALL fields are required

Show-Me ECHO

AsthmaAutismChild PsychChronic Pain ManagementCommunity Health WorkerDermatologyHealthcare EthicsHepatitis COpioid Use Disorder

Health Center

Participant

Please select which device(s) you will be using to participate in Show-Me ECHO:

Tablet (iPad or Surface Pro)Laptop/desktop computerPolycom Device

Please check the box below to confirm your acknowledgement and consent to participate as a community partner for the Show-Me ECHO project. I agree to:

  • Participate collegially in regularly scheduled Show-Me ECHO conferences by presenting cases, providing comments and asking questions;
  • Provide clinical updates and de-identified outcome data on patients as needed;
  • Keep confidential any patient information provided by other community partners during a conference;
  • Complete periodic surveys to help improve services to clinicians and other partners;
  • Use required software including, but not limited to Zoom and Box;
  • Be solely responsible for the treatment of your patients and understand that all clinical decisions rest with you regardless of recommendations provided by other Show-Me ECHO participants and;
  • Ensure that your patients are aware of your participation in Show-Me ECHO and their de-identified information could be shared.
  • Be photographed and recorded during Show-Me ECHO sessions.

I agree to the above terms

You will receive an email confirmation upon submission.