ECHO Registration Form If you plan to participate in the Show-Me ECHO, please complete the online form below. * ALL fields are required Show-Me ECHO Chronic PainAutismImpact AsthmaHepatitis CDermatologyChild Psych (available in May) Health Center Name of Organization: Phone: Street Address: City: State: Zip: County: Participant First Name: Middle Initial: Last Name: Phone: Email address: Job Title: Credentials: Please select which device(s) you will be using to participate in Show-Me ECHO: Tablet(iPad or Surface Pro)Laptop/desktop computerPolycom Device Please check the box below to confirm your acknowledgement and consent to participate as a community partner for the Show-Me ECHO project. I agree to: Participate collegially in regularly scheduled Show-Me ECHO conferences by presenting cases, providing comments and asking questions; Provide clinical updates and de-identified outcome data on patients as needed; Keep confidential any patient information provided by other community partners during a conference; Complete periodic surveys to help improve services to clinicians and other partners; Use required software including, but not limited to Zoom and Box; Be solely responsible for the treatment of your patients and understand that all clinical decisions rest with you regardless of recommendations provided by other Show-Me ECHO participants and; Ensure that your patients are aware of your participation in Show-Me ECHO and their de-identified information could be shared. Be photographed and recorded during Show-Me ECHO sessions. I agree to the above terms You will receive an email confirmation upon submission.