Welcome to the HAE Association Website

...your "Window to the World of HAE"

Please fill out the following form so that we can provide you and your family with the latest information on new and exciting HAE treatments. If you are interested in participating in any of the HAE clinical trials, please be sure to indicate that on the form. The information you provide for this database will be carefully safeguarded eliminating even the slight possibility of unauthorized disclosure.

Please Complete All Fields - Your Data Is Strictly Confidential
	First Name:
	Last Name:
	Angioedema Type
	Address:
	City:
	State:
	Zipcode
	Country:
	E mail:
	Phone:
	Date of birth:
	Attacks Per Year:
	Attend Conferences:
	Help With Organization:
	Family Members With HAE:
	Are you treated by a physician who is knowledgeable about HAE? If yes, please enter your doctor's contact info:
	Doctor's Name:
	Doctor's Address:
	Doctor's Phone Number:

Are you interested in clinical trial participation?

Yes, I'm interested No, I'm not interested

If you are interested in participating in one of the 5 on going HAE CLINICAL TRIALS for treatment of your HAE attacks. Please provide the additional information requested below.

Are You Willing To Travel And Possibly Stay At A Clinical Trial Site?:

Any other family members (immediate or extended) interested in participating in clinical trials?

Immediate Family Members' Names:

Extended Family Members:

Name:

Address:

City:

State:

Zipcode:

Phone:

Email:

Name:

Address:

City:

State:

Zipcode:

Phone:

Email:

Space for Additional Family member Contact Information (names addresses, Phone Numbers, email addresses):

Donation

Although membership is technically free, we gladly accept donations and many HAE friends who can afford to do so, contribute 35 dollars to the HAE Association.

	Amount you would like to donate: $