US Hereditary Angioedema Association

US HAEA Scientific Registry
Research for a Cure

The information you provide will be kept strictly confidential. You must complete all fields in the form to submit it.

First Name:
Last Name:
Maiden Name: (if applicable)

Gender: Male Female

Address:


City:
State:	Zip Code:

Home Phone Number:	Digits only - no spaces, dashes, or parenthesis
Cell Phone Number:	Digits only - no spaces, dashes, or parenthesis
E-mail address:
Secondary E-mail address:

Date of Birth:

Diagnosis:

Ethnicity:
American Indian or Alaskan Native Asian Black American or African American Caucasian / White Hispanic Native Hawaiian or other Pacific Islander Other or prefer not to say

Are you a member of the US HAE Association? Yes No
Do you have a blood relative with known HAE? Yes No
Do you have a blood relative with HAE who is currently participating in this research project? Yes No

What medication(s) do you currently use?
Berinert Cinryze Firazyr Haegarda Kalbitor Ruconest Takhzyro None of the above

Please select one:
I would like to enroll in the Scientific Registry only. or
I would like to enroll in the Scientific Registry, and the Ruconest Safety Registry

You will be contacted by the Registry Administrator once your Consent Forms are received and reviewed with additional information on how to access the Registry Portal.

sherryswanson@haea.org

(866) 798 - 5598

US HAEA Scientific Registry
10560 Main Street, Suite PS40
Fairfax City, VA 22030

The US Hereditary Angioedema Association
10560 Main Street , Suite PS40
Fairfax City, VA 22030

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