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:      
  Name of insurance carrier:

Other:
  Preferred Hospital for Emergencies:
  Attend Conferences:
  Help With Organization:
  Family Members With HAE:
  Doctor who treats you for HAE:
  Doctor's Address:
  Doctor's Phone Number:
  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
 
Any other family members (immediate or extended) interested in help
or support from HAEA 
 
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):

 

              



The US Hereditary Angioedema Assoc., Seven Waterfront Plaza, 500 Ala Moana Blvd., Suite 400, Honolulu, HI 96813, (866) 798-5598
Support for the HAE Association's 2009 Activities Provided by