Medication Management Student Registration

Medication Management Course

Registration Form
Refer to class schedule.

2024 32-Hour Medication Management Schedule

2024 1-Hour Refresher Schedule

Course Requested
32-Hour Course*
32-hour course is held at our training center from 8:30am-4:30pm. Participants should arrive 15-30 minutes prior to their sessions as we are unable to permit anyone in after class begins.
1-Hour Refresher*
This refresher is recommended once yearly to maintain a 32-hour certificate
4-Hour Refresher*
This refresher is recommended once yearly to maintain a 68-hour certificate
Class Date:*

Student Information
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 Information
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

Online Payment - If Billing Sponsored Employer, Submit Form Now
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.

Course Payment Options

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

*Sponsored* 32-Hour Medication Management Fee$65.00

Choose only if your residents utilize our pharmacy.

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

Contact our Training Center by phone if you wish to pay the course deposit of $50.00. (804) 285-8055

*Sponsored* 1-Hour Refresher Fee$10.00

Choose only if your residents utilize our pharmacy.

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

*Sponsored* 4-Hour Refresher Fee$25.00

Choose only if your residents utilize our pharmacy.

*Non-Sponsored* 4-Hour Refresher Fee$50.00

Total $0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Medication Management Course