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Access Adequacy & Cannulation Techniques
Vascular Access Center - Landover
1019 Brightseat Road
Landover, Maryland 20785


Registration Form
Please note that this registration page is to be completed only if paying by credit card. If you wish to pay by check, please download the registration form and mail it to us with your payment.

This workshop is open to all interested dialysis facility staff. Seating is limited, so please register early. Registration is open until close of business (5:00pm EDT) on June 11, 2008. A substitute may be sent for a registrant who is unable to attend.

 

STEP 1 -

Registrant Information

   

Name:

Job Title:

Facility:

Provider #:

Address:

 

City:

 

State:

Zip Code:

Phone:

Fax:

Email:

How would you like to receive your confirmation*?   
         *If you do not recieve a confirmation, you may not be registered!

STEP 2 - Continuing Education Credits
Please indicate if you will need education credits for:
Dietitians
Nurses
Social Workers
Technicians

Do you have Patient Care Technician certification?
Yes
No
Not Applicable

STEP 3 - Fee Schedule & Payment Method
Please indicate how you are registering (i.e. General Registration, Patient, etc.)
General Registration (on or before 6/11)  
Patients, MARC Board Members                FREE 

If you have questions about the meeting or your registration, please contact Samantha Dorr at 804-794-3757 or by email at sdorr@nw5.esrd.net.

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1527 Huguenot Road
Midlothian, VA 23113
804.794.3757
marc@nw5.esrd.net

Toll Free Patient Number 866.651.6272 © 2004 ESRD Network 5 All Rights Reserved