Veterinary Record Keeping.Com

VeterinaryRecordKeeping.com Registration Form

Veterinary Record Keeping.com 31 South 2nd Avenue Highland Park, NJ 08904 [email protected] 732-247-3737

REGISTRATION FORM

VETERINARIANS – REGISTERED VET TECHS WHO WERE ASKED BY SBVME TO TAKE A COURSE IN RECORDKEEPING

VeterinaryRecordKeeping.com is open to practicing veterinarians and registered vet technicians who were asked by the SBVME to take a course in recordkeeping. It has a RACE Approved Internet continuing education learning source focused on the Medical Record Keeping of veterinary patients.

YOU WILL RECEIVE USERNAME AND PASSWORD AFTER THE REGISTRATION FORM IS PROCESSED

Last Name ______First Name ______Degree(s) ______State License Number ______Employer: Hospital / Business Name ______Primary Doctor/Manager/Rec/Tech’s Name ______Address ______City ______State ______Zip Code ______Business Phone ______Home Phone ______How did you hear about VeterinaryRecordKeeping.com? ______

Please note that all communication from us will be primarily by email. Please provide your complete email information below. After receipt of your payment, you will receive an email confirmation from us, along with your User Name and Password. NOTE: Some Internet service providers (ISP) have an anti-spam feature that may block emails unless they have your permission. Please check your mailbox settings. You may need to authorize receipt of emails from addresses ending in “ @veterinaryrecordkeeping.com “. If you need help, please contact your ISP.

Email Address: Primary Email ______Secondary Email ______Your Website: http://www. ______

YOU ARE ORDERING:

___ 5 CE Credits- Course 1 = $299.00 ___ 5 CE Credits- Course 2 = $299.00

I have submitted payment through PayPal in the amount of $ ______on (Date) ______. I have submitted payment by check in the amount of $ ______on (Date) ______. (Please make your check payable to “Dr. Madan Kharé”) THIS PRODUCT IS NOT REFUNDABLE AND CANNOT BE EXCHANGED

Print Name ______Signed ______Date ______Please return this form via Snail Mail or email a copy of this form to mailto: [email protected]

OR MAIL TO: VeterinaryRecordKeeping.com 31 South 2nd Avenue Highland Park, NJ 08904 VeterinaryRecordKeeping.com Registration Form