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.