Join the US HAEA

…… providing wide-ranging patient services and pioneering new HAE research

Please fill out the following form so that we can provide you and your family with the most current information on HAE, including new and exciting HAE treatments. Membership includes support from a Patient Services Representative, a quarterly newsletter, news alerts, conference announcements, and access to our online discussion groups and/or Facebook page.

The US HAEA values your privacy. We will never disclose personally identifiable information to an outside party.

Please complete ALL fields. Your data is strictly confidential.

First Name:
Last Name:
Angioedema Type:
Address:
City:
State
Zip:
Country:
E-mail:
Phone:
Date of birth:
Insurance company:	Other:
Preferred hospital for emergencies:
Physician who treats you for HAE:
Physician’s address:	Physician’s phone:
Physician’s specialty:	If ‘Other’, please specify:
Would you say your doctor is knowledgable about HAE?:
Attacks per year:
Are you interested in clinical trial participation?:	Yes, I’m interested No, I’m not interested
# of family members With HAE (not including myself):
Your family members with HAE:

Comments/ Questions:

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Join the US HAEA

…… providing wide-ranging patient services and pioneering new HAE research

The US HAEA's 2011 corporate sponsors