OFFLINE PAYMENT Wholistic Pain Management 2026

Course Registration & Offline Payment

Use this form if you wish to pay for this course using a check or money order.
This course is open to veterinarians primarily and is limited to 25 people.

If you are a non-veterinarian interested in taking this course, please email Dr. Dohmen at drlaurie@purplemoonherbstudies.com prior to registering for this course.
Attendee Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell Phone Number (no landlines please)*
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Emergency Contact Person*

First NameLast Name
Emergency Contact Person's Phone Number*
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PLEASE MAKE SURE ALL THE REQUIRED INFORMATION BELOW IS CORRECT. SUBMITTING INCORRECT INFORMATION MAY RESULT IN YOUR NOT RECEIVING YOUR CE CREDITS.
Please list your Veterinary License Number(s) here.*
Type of License*

VMDDVMRVTLVTOther
Please list the state where your License Number(s) is/are valid here.*
Graduation Year & School*
Other Training
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PLEASE CHOOSE YOUR PAYMENT OPTION BELOW.
Payment Options

CHECK - $495.00MONEY ORDER - $495.00
REFUND POLICY: A $50 PROCESSING FEE WILL BE APPLIED TO ALL REFUNDS ISSUED

PLEASE NOTE THAT NO REFUNDS WILL BE ISSUED AFTER JULY 20th, 2026.
SEND YOUR PAYMENT TO:

Purple Moon Herbs & Studies LLC

1841 Bryant's Corner Road
Hartly, Delaware 19953

Checks and Money Orders should be made payable to Purple Moon Herbs & Studies LLC. Please include a copy of the confirmation email you receive, or click the Print button below to print a copy of this form.

ALL DONE? CLICK THE SUBMIT BUTTON BELOW.
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Course Registration & Offline Payment