Online Subcutaneous Course Student Registration

Online Course Registration Form

Registration Form for Online Subcutaneous Injection Training Course Only

Basic Information
Online Course Requested*
Student Name*

First NameLast Name
Course Outline:

The purpose of this course is to prepare medication aids who have successfully completed the 32 hour medication management course to administer subcutaneous injections (vials, pens, and auto-injectors) in addition to insulin. This course provides a general overview only of using these products. You will need to review the instructions that came with your medication for specific usage, storage, and disposal instructions. If you still have questions after completing this course and reviewing your medication instructions please reach out to the prescribing provider or your pharmacy.
I acknowledge the course outline.*

YesNo
Social Security Number of Student*
Virginia requirements due to certificate program. Used only in secure formats.
Proof of Medication Administration Training*

Browse Files
Please upload your latest medication management certificate and your latest refresher course so our staff may verify you are eligible for this training course. (If it has been less than one year since your initial certification, you do not need to upload proof of refresher) Cancelof
Email Address of Student*
Required. Must be student's email address, not email address of employer.
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:*
Type "Self Pay" if taking course outside of a sponsored employer.
Billing Address of Sponsored Employer

Street Address

Street Address Line 2 including ATTN Contact

CityState

Zip Code
- After registration, an online course link is email to students weekly on Mondays by 4pm (excluding holidays). Please utilize students' direct email addresses for emails to be sent.
- Once the course is sent out via email, each student has 7 days to access the course. If the course is not accessed in this time the link to the course will expire.
- Please allow up to 10 business days for our staff to verify results of the quiz and for results to be graded and sent.
- Results are sent weekly, by the end of the business day on Thursdays. If you have not received your results, please wait until the next Thursday or contact our course contacts:
  - Thomas Bevan, Course Administrator thomas.bevan@bremorx.com
  - Jamie Coleman, Instructor jamie.coleman@bremorx.com
I understand the above conditions to the online course.*

YesNo
Comments

Credit Card Payment

Online registration requires payment upon registration of the course.*

*Sponsored* Subcutaneous Injection Training Fee$10.00

Select this option if your facility uses Bremo LTC Pharmacy as their preferred pharmacy

*Non-Sponsored* Subcutaneous Injection Training$20.00

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

Should be Empty:

Online Course Registration Form