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AGS ECHO Healthcare Professional Recommendations
Note: The AGS ECHO Program respects the privacy of all individuals involved and will handle the provided information with utmost confidentiality.
https://agsaa.org/privacy
Please provide us with the name and contact information of any healthcare professional you believe would benefit from this program, and we'll ensure they receive all the information they need when the AGS ECHO program is ready. Your recommendation could play a vital role in shaping the future of healthcare in our community.
Learn more at
https://agsaa.org/echo
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* Indicates required question
Email
*
Your email
Healthcare Professional's Full Name
*
Your answer
Healthcare Professional
's Medical Specialty
*
Neurology, Rheumatology, Physical Therapy, Cardiology, etc.
Your answer
Nominee's Contact Information
*
Any of the following:
Email Address
Phone Number
Institution/Location
Hospital/Practice Website
Your answer
What is the professional's degree of experience with AGS?
*
No direct experience with AGS
1
2
3
4
5
Experience with many AGS patients
How involved do you think the nominee should be in the AGS ECHO Program?
*
Invited as a participant
1
2
3
4
5
Invited as speaker
Send me a copy of my responses.
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