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Become a member of the Scientific Registry

Thank you for choosing to become a member of the US HAEA Scientific Registry. Your participation is key to future medical research! This research will change lives – yours, those of your loved ones and everyone whose lives are affected by HAE.

Please be sure to read all of the information provided on the Scientific Registry page and the Frequently Asked Questions before registering to participate.

Once the Registry Administrators verify that you qualify for membership, you will receive a confirmation letter along with a Consent Form to sign and return.

Your participation will make a difference!

To register to participate, please complete the entire form. If you have any questions about registration, please call 1-866-798-5598. NOTE: The information you provide will be kept strictly confidential

Contact Info
First Name:	Middle Initial:
Last Name:
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Date of Birth:	month January February March April May June July August September October November December day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 year 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
HAE Info
Have you been diagnosed with HAE?   Select HAE Type I HAE Type II HAE with Normal C1 Inhibitor Acquired Idiopathic I’m not sure what type Undiagnosed I do not have HAE
Are you a member of the HAE Association? Select Yes No
Do you have a blood relative with known HAE? Select Yes No
Do you have a blood relative with HAE who is currently participating in this research project? Select Yes No