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EMR Self-Paced

1Student Information

2Course Options

3Agreement & Payment

Student Information
Full Name*
First Last
Email Address*
Please use your personal email address rather than a work or school account. Course instructions will be emailed to this address, and it will also become your username for logging into the online course.
Enter Email Confirm Email
Phone Number*
Just in case we can't reach you by email.
And your mailing address?
Please note the state of New York does not accept our courses.

Street Address Address Line 2 City State ZIP Code

Terms & Conditions
Course Time Commitment*
- I understand and agree that at least 30-40 hours of learning is needed to complete the online coursework, and the deadline for finishing the online coursework is one week before the first day of my Skill Training class.
Terms and Conditions*
- I understand and agree to the TERMS AND CONDITIONS
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Signature of Student
By typing my first and last name below, I verify understanding and agree to the terms and conditions. I also verify that the person completing this form is the student enrolling in the course.
First Last
Payment
Promo Code
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Northwestern Health Verification*
- I verify that I am currently a student or faculty/staff member of Northwestern Health Sciences University.
Total
$0.00
Payment Method*
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Invoice to a Sponsoring Organization
Did your organization give you a code to enter when registering?*
Organization ID Code*
Name of Organization*
Contact Person at Organization*
First Last
Phone of Contact Person*
Email of Contact Person*
Enter Email Confirm Email
Mailing Address of Organization*
Street Address Address Line 2 City State ZIP Code
Instruction for Submitting Invoice
Enter any specific instructions we should know about submitting an invoice to this organization (for example: what to include in the memo, etc).
Invoice Terms and Conditions*
- I understand and agree that the organization above has authorized payment for my course fees, and payment must be received by the due date indicated on the invoice otherwise my course registration will be canceled.

EMR Self-Paced

Student Information

Course Options

Terms & Conditions

Payment

Invoice to a Sponsoring Organization