Member ID Card
Get Yours Today!

We have wallet-sized ID cards available for HAE patients. The card contains links to online, authoritative HAE information. Inside the folded wallet card, you can enter your personal and medical information.

You may wish to coordinate with your physician on what information to include.

Carry your ID card with you, and be sure to get one for each of your HAE-affected family members.

Simply fill out the online form for your card, and for each additional card request. Not all of the information collected in the form will appear on your I.D. card.

Please remember you can also always contact your Patient Advocates Team Member with any HAE concerns you may have.


Complete the form below to get your ID card.

Member Name: 
 
Address: 
 
 
City: 
State:    Zip Code: 
 
Telephone Number: 
Cellular: 
E-mail address: 
 
Date of Birth: 
 
Angioedema Type: 
 
Insurance Company: 
Preferred Hospital for Emergencies: 
 
Physician Who Treats you for HAE: 
Physician's Specialty: 
Is your doctor knowledgeable about HAE?  
 

Physician's Address: 
 
 
City: 
State:    Zip Code: 
 
Physician's Telephone Number: 
Treating Physician's
After-Hours Telephone: 
 
Emergency Contact Name: 
Emergency Contact Telephone: 
 
 
Pharmacy Name: 
 
Pharmacy Address: 
 
 
City: 
State:    Zip Code: 
 
What medication(s) do you currently use?









 
Attacks Per Year: 
 
Number of Family Members with HAE:  
(not including yourself) 
 
Are you Interested in Participating
in a Clinical Trial?