Project ECHO for ILD Registration

First Name *

Last Name *

Email *

Re-Enter Email *

Phone Number

Field of Practice (Pulmonology, Radiology, Primary Care, etc.) *

Name of Organization/Health Center/Clinic *

Organization's City *

Organization's State/Province/Region *

Organization's Country *

How did you learn about Project ECHO for ILD? *

How did you learn about Project ECHO for ILD? Other

What interests you in joining Project ECHO for ILD? (Check all that apply) *

To become a well-trained local provider for patients with ILD

To diagnose patients with ILD

To screen and refer patients with ILD to specialists for treatment

To manage and treat patients with ILD using best practice therapies with the support of Project ECHO for ILD

To become local expert in ILD in my community, and to provide consultation to other community providers in the care of patients with ILD

To continue providing care for patients with ILD in the future, with regular participation in Project ECHO for ILD

To continue providing care for patients with ILD in the future, without regular participation in Project ECHO for ILD

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