AOD ECHO Network Enrolment Question Title * 1. First name Question Title * 2. Last name Question Title * 3. Email address Question Title * 4. Mobile number Question Title * 5. What is your profession? GP Specialist Non- GP Specialist (please select other and specify) Nurse IMG Junior Doctor Pharmacist Allied Health Professional (please select other and specify) Other (please specify) Question Title * 6. Workplace name Question Title * 7. Workplace suburb Question Title * 8. Is your work location classified as: Metropolitan SA Regional SA Remote SA Question Title * 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 Question Title * 10. Do you have a patient case you would like to discuss at the network? Yes No Unsure Question Title * 11. What would you like to gain from joining the AOD ECHO Network? Question Title * 12. How did you hear about the AOD 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) Question Title * 13. If you are a RACGP member and would like to claim points for participating in this Peer Group Learning Accredited Activity (Reviewing Performance Category 1), please provide us with your RACGP membership number. Question Title * 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. Thank you for completing this enrolment form. We will be in touch shortly to confirm your enrolment. Submit response >>
