Name *

*The name you'd like to be called*

First Name

Last Name

Phone *

(###)

###

####

Address *

Please include your zip code's 4 digit extension. This information is used to identify your elected officials to support bleeding disorder advocacy efforts.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Relationship to the Bleeding Disorders' Community *

Select all that apply

Person with a Bleeding Disorder

Caregiver to someone with a Bleeding Disorder

Family Member to someone with a Bleeding Disorder

Friend to someone with a Bleeding Disorder

Medical Professional/Researcher

Other Chapter/Patient Advocacy Organization

Pharmaceutical Representative

Healthcare Provider

Donor

Other

What racial/ethnic group(s) do you identify with? *

Select all that apply

Asian

Black and/or African American

Indigenous/American Indian/Alaska Native

Latinx/Hispanic

Middle Eastern

Pacific Islander

White/Caucasian

Unknown

Other

Prefer not to state

Type of Bleeding Disorder *

Select all that apply

Hemophilia A

Hemophilia B

von Willebrand

Factor I

Factor II (Prothrombin)

Factor V

Factor VII (Proconvertin)

Factor X (Stuart-Prower)

Factor XI (Hemophilia C, Plasma Thromboplastin Antecedent, Rosenthal Syndrome)

Factor XII (Hageman Factor)

Factor XIII (Fibrin Stabilizing)

Sickle Cell Disease

Paroxysmal Nocturnal Hemoglobinuria

Bleeding of Unknown Cause

Undiagnosed

None of the Above

N/A

Please indicate how we may use the information povided

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Add me to any mailing lists that are specific to my identity

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