Phlebotomy Skills Refresher Workshop Enrollment Form

Phlebotomy Skills Refresher Workshop Enrollment Form

Prerequisite: Participants must have previous phlebotomy training or hold a healthcare license in a profession where blood collection skills are utilized. Proof of previous training or professional licensure is required prior to enrollment.
Personal Information
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Professional Background
Current Profession (Choose one):
Employer (if applicable):
Have you previously completed a phlebotomy training program?
If yes, where?
When was the last time you routinely performed blood draws?
Workshop Session
Please select your preferred workshop session. All sessions are on Monday, Wednesday and Friday from 12pm-3pm.
Eligibility Verification

This workshop is intended for healthcare professionals and individuals with previous phlebotomy training.
Please upload your professional license or certification.

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Workshop Acknowledgment
- I understand this workshop is intended for individuals with previous phlebotomy training or healthcare experience.
- I understand this workshop is designed to refresh and strengthen existing blood collection skills.
- I understand this workshop does not provide national certification or phlebotomy licensure.
- I understand successful completion of this workshop does not qualify me to work as a phlebotomist if I do not otherwise meet employer or certification requirements.
- I understand live venipuncture practice may be performed during this workshop.
- I agree to follow all safety policies, infection control guidelines, and instructor directions while participating.
- I understand that enrollment may be denied or canceled if I do not meet the prerequisite requirements.
Eligibility Attestation
I certify that all information provided on this application is true and accurate. I understand that Lotus Healthcare Academy reserves the right to verify my training, certification, professional license, or employment history. I understand that providing false information may result in denial of enrollment or dismissal from the workshop without a refund.
Workshop Registration Fee
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Phlebotomy Skills Refresher Workshop
$199.00 Quantity

Total

$0.00
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Phlebotomy Skills Refresher Workshop Enrollment Form

Personal Information

Emergency Contact

Professional Background

Workshop Session

Eligibility Verification

Workshop Acknowledgment

Eligibility Attestation

Workshop Registration Fee *

Workshop Registration Fee