SHEmophilia Initiative Sign-Up Form

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Please use this form to register for a quarterly medical professional sessions. NEXT SESSION August 26, 2024 with Dr. Vanessa Salinas and Dr. Fernando Corrales-Medina
First Name/el primer nombre*
Last Name/el apellido*
Email Address/correo electrónico*
I am a/Soy una: (Check all that apply.)/marque todo lo que corresponda*

Patient/PacienteParent of a patient/Madre de una pacienteSpouse or Significant Other of a Patient/Esposa, Otra significativaOther/Otra
Patient Diagnosis Pertinent to you/diagnóstico para ti: Select Multiple if Applicable/seleccione varios si corresponde.*

Factor I/factora 1Factor 5 Deficiency (NOT LIDEN)Factor 7 DeficiencyFactor 8 DeficiencyFactor 8 Deficiency with Inhibitor ComplicationsFactor 9 DeficiencyFactor 9 Deficiency with Inhibitor ComplicationsFactor 10 DeficiencyFactor 11 DeficiencyFactor 13 Deficiencyvon Willebrand diseaseGlanzmann's ThrombastheniaPlatelet Defect or ConditionDense Body Storage Pool DisorderOther
Would you like future resources on programs we offer?: ¿Le gustaría recursos futuros sobre los programas que ofrecemos?*

All CHES Foundation Alerts/todas las alertasLet me choose which programs I want to hear about/dejame elegir
Please SELECT ALL you would like to sign up for:*

Webinar InvitesAfter the Shock: Inhibitor Camp (0-18 yrs)LadyBugs ProgramLifeLines for Health Newsletter (annual publication)Digital Newsletter (bi-weekly)Momentum: Adult Inhibitor Retreat (18 and up)LEVERAGE: Adult Inhibitor Camp (18 and up)One Drop: Rare Bleeding Disorders Consortium (Rare Factor and Platelet Conditions)Paid Surveys (Patients Only)Presentation Material from Events and SpeakersInformational Mailings Pertinent to You
Preferred method to contact: (Check all that apply) *Note: If your mailing address is outside of the United States, we recommend you choose "email", as we cannot guarantee delivery to other countries.*

EmailMailPhone
Address*

Street Address

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CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Number is a:*

Home PhoneMobile PhoneWork Phone
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By submitting this form, you understand that you are voluntarily agreeing to receive periodic emails and/or mailings of CHES resources. For more info on CHES Foundation, you may visit: https://ches.foundation
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