Alaska Medical Provider ECHO
Presenter Name:
Presenter Role:
Community:
Date:
/
Month
/
Day
Year
Date
Does your question relate to a
Patient
Procedure in your practice
Mandates and Protocols
Testing
Treatment
Other
Section 1
Brief summary of presenting case:
Significant past medical history or co morbidities:
Current medications (if relevant):
What help would you like from the panel?
Section 2
Brief summary of presenting problem:
What help would you like from the panel?
Question:
Preview PDF
Submit
Should be Empty: