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Join The 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.
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Last Name:
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(if applicable)
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Date of Birth:
Diagnosis:
HAE Type I
HAE Type II
HAE with normal C1 inhibitor
Acquired
Idiopathic
I have HAE but not sure what type
Undiagnosed
I do not have HAE
Ethnicity:
American Indian or Alaskan Native
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Caucasian / White
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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.
Sign Up Today!
Have questions?
Contact Registry Administrator
Sherry Swanson
sherryswanson@haea.org
(866) 798 - 5598
US HAEA Scientific Registry
10560 Main Street, Suite PS40
Fairfax City, VA 22030