US Hereditary Angioedema Association

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