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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?

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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:

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* 9. Would your work environment be described as

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

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

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* 12. For each of the curriculum topics listed below, please share your learning needs and requests for specific focus areas:

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* 13. How did you hear about the Dementia ECHO Program?

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* 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)

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* 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?

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