Medication Management Student Registration

Basic Information
Course Requested*
Class Date:*
Student Name*

First NameLast Name
Social Security Number of Student*
Virginia requirements due to certificate program. Used only in secure formats.
Email Address of Student*
example@example.com - Type "none" if not available.
Student Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number of Student*
Sponsored Employer*
Type "Self Pay" if taking course outside of a sponsored employer.
Email Address of Sponsor*
example@example.com
Phone Number of Sponsored Employer:
Leave blank if self-pay
Billing Address of Sponsored Employer

Street Address

Street Address Line 2 including ATTN Contact

CityState

Zip Code
Comments
If NOT paying by credit card, you may scroll down and submit the form without completing the product/payment information.
Credit Card Payment

Required for non-sponsored students or students of employers not sponsored with Bremo Long Term Care Pharmacy.

Sponsored Employers that have an internal charge account with Bremo Long Term Care Pharmacy are not required to pay with credit card, but are welcome to do so.

Choose Course *Only* if Paying Online

Choose Course Fee *Only* If Paying with Credit Card Online

*Sponsored* 32-Hour Medication Management Fee$65.00

*Non-Sponsored* 32-Hour Medication Management Fee$275.00

*Sponsored* 1-Hour Refresher Fee$10.00

*Non-Sponsored* 1-Hour Refresher Fee$20.00

4-Hour Refresher Fee$50.00

Total $0.00

Medication Management Course