Pre-Registration Form
Please fill in the form as much as possible to help us better serve you. All of the information you provide is kept confidential and shall not be shared or sold to other parties. Alternately if you wish to contact us by email, telephone, or regular mail: our contact information is provided on this page in the grey columnn which borders the right side of this form. We strive to answer all requests within one business day or sooner.
Select the courses you are interested in from the list below.
Short IV Insertion
Refresher IV Insertion
Central Line Care and Maintenance
PICC/Midline Care and Maintenance
Phlebotomy for Nursing Personnel
Self Study IV Classes -coming soon!-
Request Company Brochure
Prefer Contact By:
Email
Phone
Select your Profession
Manager of IV/PICC Dept
Director of Nursing
IV Team Member
Registered Nurse
Licensed Practical Nurse
Physician
Advanced Practitioner
Paramedic
EMT
Certified Nurses Assistant
Radiology Technologist
Other Health Care Professional
Student Nurse
Medical Student/Intern
Allied Health Care Student
Choose your Work Setting
Hospital
Long Term Care or Rehab
Infusion Center or Clinic
Home Care Agency
Home Infusion Pharmacy
Physician's Office
Outpatient PICC Service
Radiology
Other
Please choose your degree of IV and/or Phlebotomy Experience
Very limited
Good, want to advance training
Past skills good, need review
Excellent, want to advance
Select your timeframe/need for training
Class needed within the next 2-3 months
Class needed within 6 months
Class needed ASAP, save space and contact me right away!
I am interested in scheduling a class at my facility
Requesting information only for future date
Select number of participants interested in course
One
Two
Three
Four
Five (discount for group of five or more)
Eight or more
Ten or more
Fifteen or more
Twenty or more
IMPORTANT! Tell us how you heard about us!
PICC Resource Brochure or AD
Referral from customer
Returning customer
Google search
Yahoo! search
MSN search
About search
Other search engine
IV-Therapy website
New York Nurses Assoc. site
CT League for Nursing site
CT League for Nursing booklet
LITE website
NNBA website
CT INS chapter
other
PICC Resource Associates, LLC
55 Peace Acre Lane
Stratford, Connecticut 06614
OFFICE or FAX: (203) 377-5252
TOLL FREE: (888) 333-5171
GENERAL EMAIL: info@piccresource.com
CONTACT:
Alice Cennamo, President
EMAIL: alice@piccresource.com