2015 Madison Clinical Conference The Pharmacists Role in


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
$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 _________________________________________________________________
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
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.