PHLEBOTOMY TRAINING REGISTRATION FORM

PHLEBOTOMY TRAINING

REGISTRATION FORM

Phlebotomy Class Dates - First Choice*

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Phlebotomy Class Dates - Second Choice

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Training Location

Since locations may vary by class, we will notify you via e-mail the location of your training.

First Name

Last Name

OHSU e-mail

Credentials

OHSU Job Role

Department Name and Physical Location

Department Manager Name

Department Manager e-mail

Previous Phlebotomy Experience

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In order to secure a spot you must provide a valid alias and FAID.

Billing Alias

This will be eight numbers

Billing FAID

This will generally be four letters followed by four numbers

Please e-mail CTRC@ohsu.edu if you have any questions

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