Name *

First Name

Last Name

I am *

Person with hemophilia B

Parent or caregiver of someone with hemophilia B

Partner of someone with hemophilia B

Sibling of someone with hemophilia B

Relative of someone with hemophilia B

Industry

Home Care

Media

HTC/Social Worker

I am interested in receiving information about:

Annual Symposium

Member Retreats

Beats Music Program

Generation IX

Local/State Meetings

Who in the household has Hemophilia B? (Check all that apply)

Self

Partner/Spouse

Son

Daughter

Other [Please specify]

How did you hear about us?

Chapter

HTC

Doctor

Pharmaceutical Rep/Liaison

Social Media Group

Exhibit Booth

Hospital

Community Friend

Homecare/specialty pharmacy

Google

Social Media

Other

DOB (Person #1 with Hemophilia B) *

MM

DD

YYYY

DOB (Person #2 with Hemophilia B)

MM

DD

YYYY

DOB (Person #3 with Hemophilia B)

MM

DD

YYYY

Phone *

(###)

###

####

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country