Infectious Disease ECHO (NPAIHB)

To submit a case, fill out the form below.

Prefer to complete it in your own time? Download this form and email it to the contact listed on the form.

If you have any questions about this case form, please contact jrienstra@npaihb.org or echo@npaihb.org.

Your Name(Required)

Presenter Information

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Patient Information

Relevant Medical Diagnoses

Medical Diagnoses
Substance Use Disorder
Joint Replacement
Solid Organ Transplant
Cancer
Other

Case Summary

Current Medications

Medications
Medication Name
Dosage
Frequency
 

Labratory/Physical/Imaging

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By submitting this form, you have acknowledged that Project ECHO case consultations do not create or otherwise establish a provider-patient relationship between an ECHO clinician and any patient whose case is being presented in a teleECHO session. Always use Patient ID# when presenting a patient in clinic. Sharing patient name, initials or other identifying information violates HIPAA privacy laws.