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Advanced Dementia ECHO Enrolment Form
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1.
First name
(Required.)
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2.
Last name
(Required.)
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3.
Email address
(Required.)
4.
Mobile number
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5.
What is your profession?
(Required.)
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
(Required.)
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7.
Workplace suburb
(Required.)
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8.
Is your work location classified as:
(Required.)
Metropolitan SA
Regional SA
Remote SA
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9.
Would your work environment be described as
(Required.)
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?
(Required.)
Yes
No
Unsure
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11.
What would you like to gain from joining the Dementia ECHO?
(Required.)
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12.
For each of the curriculum topics listed below, please share your learning needs and requests for specific focus areas:
(Required.)
Dementia and memory assessment in primary care and aged care.
Dementia prevention and addressing modifiable risks.
Critical care conversations with family and people living with advanced dementia.
Advanced care planning for people living with dementia.
Care planning in complex patient presentations and situations.
Management of neuropsychiatric symptoms of dementia.
End of life care in advanced dementia.
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13.
How did you hear about the Dementia ECHO Program?
(Required.)
SAPMEA
Adelaide PHN
Country SA PHN
SA Health / Wellbeing SA
GP Integration Unit
Direct email invitation
Social media
Word of mouth
Other (please specify)
14.
If you are an RACGP member please provide your RACGP ID.
Participants will receive 1 CPD hour under the Reviewing Performance category with RACGP for each session attended.
GPs presenting a case for discussion, will receive 1 CPD hour under the Measuring Outcomes category (to be self-claimed)
15.
If you are an ACRRM member please provide us with your ACRRM membership number.
Participants will receive 1 CPD hour under the Reviewing Performance category with ACRRM for each session attended.
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16.
Would you like to subscribe to our fortnightly newsletter?
(Required.)
Yes
No, I am already subscribed
Ni, I am not interested
