Member Database Form

CONTACT INFORMATION

Thank you for assisting us in updating your information in our database. This form should be completed by individuals 18-years of age or older. If you have an 18+ individual, living with a bleeding disorder in your household, please have them complete their own form.

Question Title

* 1. Primary Contact (must be 18+)

First and Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Home Phone Number

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* 2. Cell Phone Number

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* 3. What is your preferred method of contact?

Mail

Mail & Email

Phone

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* 4. Date of Birth (we want to wish a Happy Birthday!)

Date / Time

Date

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* 5. Primary Language

English

Spanish

Other (please specify)

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* 6. Have you been diagnosed with a bleeding disorder?

Yes

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* 7. If diagnosed, what is your diagnosis?

Carrier

von Willebrand Disease

Factor 5 Deficiency

Factor 7 Deficiency

Factor 8 Deficiency (Hemophilia A)

Factor 9 Deficiency (Hemophilia B)

Factor 11 Deficiency (Hemophilia C)

Factor 12 Deficiency

Factor 14 Deficiency

Glanzmann's Thrombasthenia

Not Diagnosed

Other (please specify)

Question Title

* 8. Are you affiliated with a pharmaceutical company, specialty pharmacy, or any other business that earns revenue from serving the bleeding disorders community? This would include industry representative/employee, contracted speaker, etc. If yes, please tell us your roll and which company.

Yes (please specify)