vWD Study Opportunity
This form is a screener for the Observational "Velora Discover" Study by HEMAB Therapeutics. Please allow 2 business days upon completion for a response to your application. If more than one person in your household may qualify, please complete additional screeners as neccessary.
Are you applying for yourself or for your child?
*
Myself
My child, who is under age 18 and capable of discussing personal health experiences
Your Name
*
First Name
Last Name
Child's Name
*
First Name
Last Name
Applicant's Gender - at Birth
*
Female
Male
Other
Applicant's Date of Birth
*
-
Month
-
Day
Year
Date
Medical Info
I confirm that I have been diagnosed with vonWillebrand Disease (vWD) by a licensed medical expert with the following severity:
*
Type 1
Type 2
Type 3
Unknown
Other
I confirm that my named child (above) has been diagnosed with vonWillebrand Disease (vWD) by a licensed medical expert with the following severity:
*
Type 1
Type 2
Type 3
Unknown
Other
Subtype, if known
Most recent vWF (vWillebrand factor) level
*
If unknown, write "NA".
Approx. date vWD level was taken
*
-
Month
-
Day
Year
Most recent FVIII (factor 8) level
*
If unknown, write "NA".
Approximate date FVIII level was taken
*
-
Month
-
Day
Year
Approximate number of TREATED bleeds per year
*
Suffering from Heavy Menstrual bleeding?
*
Yes, a lot
Somewhat
No, not at all
Product(s) used to treat bleeds
*
Contact Info
If applying for your child, please provide YOUR contact info.
Email
*
Confirmation Email
Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
By signing below,
I agree to be contacted by Eric Lowe at CHES Foundation for any clarifications on my application, as well as, to carry out project completion. I further agree that all information provided in this form is true and accurate to the best of my knowledge. I understand final selection of applicants will be at the sponsor's discretion. Therefore, I give CHES Foundation permission to share any necessary PI (personal information) provided on this application to properly make a decision on admittance. All PI on this form is protected under our Private Policy Guidelines, which can be found at: https://ches.education/privacy-policy
Signature
Submit
By submitting this form, you are agreeing to receive periodic mailings about CHES programs that are relevant to your medical condition. If you wish to unsubscribe or edit your preferences, you may visit https://ches.education/communications-profile-form
Should be Empty: