Dermatology ECHO

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 echo@npaihb.org.

MM slash DD slash YYYY
Please enter a number less than or equal to 125.
Sex at Birth
Include location/site, and how long the patient has had this condition
E.g. biopsy, cryotherapy, injection, KOH, scabies prep, culture, etc.
Current Medications
Medication
Dosage
Frequency
 
Max. file size: 30 MB.

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.