Phlebotomy Enrollment & Registration Form – Peach State Medical Institute

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Name* This field is required.

First Name

Last Name

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Phone Number* This field is required.

Please enter a valid phone number.

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Email* This field is required.

example@example.com

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⚠️ Seats are first come, first served. Your seat is NOT reserved until payment is received.

If you haven't done so, please submit your initial deposit of $200.00 on our website: www.peachstatemedicalinstitute.com to secure your seat.

This $200 deposit is non-refundable and goes towards your total tuition. If the student is unable to attend the class they originally enrolled for then their deposit may be applied towards an upcoming class. Please contact admissions at 678-602-2907 if you are unable to attend class!

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Will you be using a payment plan?* This field is required.The total tuition for the Phlebotomy Technician Training Program is: $1,300.00. After paying your initial deposit of $200.00, the remaining balance of $1,100.00 can be paid via a payment plan option or paid in full. Please indicate if you will be using a payment plan option or paying the remaining tuition of $1,100.00 in full below.

Yes, I will use a payment plan to pay the remaining tuition of $1,100.

No, I will pay the remaining tuition of $1,100.00 in full.

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Payment Plan Options* This field is required.We offer weekly and bi-weekly payment plan options. Please note that your first payment is due on the first day of class. Please contact admissions at 678-602-2907 if you have any questions regarding payments or billing. Please select your payment plan option below.

4 weekly payments of: $275.00

2 bi-weekly payments of: $550.00

I will pay the remaining tuition of $1,100.00 in full

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Payment Agreement* This field is required.I understand that my seat is not reserved until a $200.00 deposit is submitted. The initial deposit can be submitted by going to www.peachstatemedicalinstitute.com. I understand that my remaining balance must be paid in full on or before the last day of class.

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HIPPA Agreement* This field is required.I understand that during training I may be exposed to confidential information and agree to follow HIPAA guidelines at all times. I agree to follow HIPAA guidelines.

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Liability Waiver* This field is required.I understand that this training includes hands-on practice and I accept all risks. I release Peach State Medical Institute from liability. I agree to the liability waiver

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I give permission for photos/videos taken during training to be used for educational or promotional purposes.* This field is required.

YESNO

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Student Policy Agreement* This field is required.I agree to follow attendance requirements, payment terms, and all school policies. No refunds after class begins. I agree to all student policies

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Signature* This field is required.