Describe your case and your main question you would like addressed by the ECHO participants. After submitting your case, you will be assigned a presentation date.
Note: If you do not have information for a category, just insert "unknown", "not applicable (NA)" or a blank space to move to next question.
Do not include and Protected Health Information (PHI).
By submitting this survey you have acknowledged that Project ECHO case consultations do no create or otherwise establish a provider-patient relationship between any ECHO clinician and any patient whose case is being presented in a teleECHO clinic.