Request for Help with Finding a Doctor

Request for Help with Finding a Doctor

CALIFORNIA RESIDENTS - Please complete information below and a Community Health Worker will follow up with you. If you have questions please send an email to deborahg@scdfc.org or call the SCDF at (909) 743-5226.
OUTSIDE OF CALIFORNIA - We will try to help as best we can. Please allow up to 10 days for us to get back to you.
This form is HIPAA compliant and all information provided is confidential. For a copy of our HIPAA Notice of Privacy Practices, click here.
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Age Range of person with SCD:*
Contact Number:*
E-mail*

Confirmation Emailexample@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current type of insurance:*
What type of doctor are you looking for?*

Hematologist (SCD Specialist)Primary Care ProviderPain SpecialistI don't know
Would you like to receive information on the following therapies for people with SCD?*

Hydroxyurea (FDA approved in 1998 for SCD)Endari (FDA approved in 2017 for SCD ages 5+)Oxbryta (FDA approved in 2019 for SCD ages 4+)Adakveo (FDA approved in 2019 for SCD ages 16+)Bone Marrow/Stem Cell TransplantsGene Therapy (FDA approved Dec 2023 for SCD ages 12+)Covid 19 vaccine (recommended for people with SCD)Not at this timeOther
Comments/Questions:
Should be Empty: