2015 Madison Clinical Conference The Pharmacists Role in

2015 Madison Clinical Conference
The Pharmacists Role in Management of the Patient with Diabetes
March 24-25, 2015
Three ways to register:
1. Online at http://ce.pharmacy.wisc.edu/2015MadisonClinicalConferenceInfo
2. By phone at 608-262-3132, toll-free at 877-947-4255 or fax at 608-262-2431
3. Mail this completed form with check payable to University of Wisconsin. Mail to: UW-Madison School of
Pharmacy, 2015 Madison Clinical Conference, Division of Pharmacy Professional Development, 777 Highland
Ave, Madison, WI 53705-2222
REGISTRATION RATES
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$265 Pharmacist Registration
$350 Pharmacist Registration after March 2
$165 Pharmacist Registration-Single Day
$190 Retired Pharmacists/Clinical Instructors (must be received by March 2 to qualify)
Name _________________________________________________________________
Last
First
Middle I.
Address _______________________________________________________________
City __________________________________ State _______ Zip _________________
Telephone (______) ________________ Fax: (______) ____________
Email Address* __________________________________________________________
*An email address is required to receive confirmation of your registration. You will receive emails from [email protected]
Indicate Workshop choices/preferences:
First________; Second________; Third________; Fourth________; Fifth________
(Please use the letter-e.g., A,B,C,etc.-corresponding to the “Session” title as indicated in the brochure to
identify your choices. Session assignments will be made in order of receipt of registrations. Please list five
choices; while every attempt will be made to provide you with your top three choices, no guarantees can be
made.)
Make checks payable to the University of Wisconsin
We accept: MasterCard, Visa, Amer Express, Discover
Card Number _____________________________________________Expiration Date ____________________
Cardholder’s name __________________________________________________________________________
Mail or fax to: UW-Madison School of Pharmacy
2015 Madison Clinical Conference
Division of Pharmacy Professional Development
777 Highland Avenue
Madison, WI 53705-2222
fax: 608.262.2431
Questions: Contact:
Dr. Al Hanson
Conference Coordinator
PHONE: 608.262.3132
email: ce.pharmacy.wisc.edu
Refund Policy: If it is necessary to cancel a registration, a refund, less an administrative fee of $50, will
be provided if notification is received prior to March 2. No refunds will be issued after that date.