CKD ECHO Enrolment Form 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 also select other and specify) Nurse IMG Junior Doctor Pharmacist Allied Health Professional (please also 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 CKD ECHO? Question Title * 12. For each of the curriculum topics listed below, please share your learning needs and requests for specific focus areas: Screening and diagnosis of CKD Hypertension and Cardiovascular health in CKD Diabetic Kidney Disease Pharmacological and non-pharmacological interventions to slow CKD progression Specialist referral, including specialist vs GP prescribing Question Title * 13. How did you hear about the CKD ECHO Program? SAPMEA Adelaide PHN Country SA PHN GP Integration Unit Direct email invitation Social media Word of mouth Other (please specify) Question Title * 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) Question Title * 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. Question Title * 16. Would you like to subscribe to our fortnightly newsletter? Yes No, I am already subscribed No, I am not interested Submit response >>
