Cardiology ECHO Network Waitlist Enrolment Form

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* 1. First name

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* 2. Last name

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* 3. Email address

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* 4. Mobile number

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* 5. What is your profession?

GP Specialist

Non- GP Specialist (please also select other and specify)

Nurse

IMG

Junior Doctor

Pharmacist

Allied Health Professional (please also select other and specify)

Other (please specify)

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* 6. Workplace name

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* 7. Workplace suburb

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* 8. Is your work location classified as:

Metropolitan SA

Regional SA

Remote SA

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* 9. Would your work environment be described as

Solo practice

Team of practitioners from the same clinical discipline

Team of practitioners of different clinical disciplines

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* 10. Do you have a patient case you would like to discuss at the network?

Yes

Unsure

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* 11. What would you like to gain from joining the Cardiology ECHO Network?

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* 12. How did you hear about the Cardiology ECHO Network?

SAPMEA

Adelaide PHN

Country SA PHN

SA Health / Wellbeing SA

GP Integration Unit

Direct email invitation

Social media

Word of mouth

Other (please specify)

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* 13. If you are a RACGP member and would like to claim 40 points for participating in this Peer Group Learning Accredited Activity (Reviewing Performance Category 1), please provide us with your RACGP membership number.

Note: RACGP members who attend at least 4 sessions and participate in both the planning and review meeting will be eligible to receive 40 points (Cat 1) for a Reviewing Performance activity under the Peer-Group Learning model. RACGP members who do attend fewer than 4 sessions, will still receive an attendance certificate to self-claim Cat 2 points.

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* 14. If you are an ACRRM member and would like to claim points for participating in this Case Discussion Activity (Performance Review Category), please provide us with your ACRRM membership number.