OBDC Statehouse Day
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Chapter
*
Greater Ohio Bleeding Disorder Foundation
Northwest Ohio Hemophilia Foundation
Southwestern Ohio Hemophilia Foundation
TSBDF (Greater Cincinnati)
No Chapter Connection
HTC
*
Children’s Hospital Medical Center of Akron
Cincinnati Children’s Hospital Medical Center
Nationwide Children’s Hospital
Dayton Children’s Medical Center
Northwest Ohio Hemophilia Treatment Center
Ohio State University Medical Center
University Hospitals Health System
University of Cincinnati Medical Center
Independent Physician (please share name below)
If chose Independent Physician above, please share name here.
Bleeding Disorder
*
Hemophilia A
Hemophilia B
von Willebrand Disease
Other - please list below
Other
Hotel Room (s) Needed
*
Number spending the night
*
How many will join us for breakfast?
*
How many will attend meetings?
*
Please list names of all meeting attendees including yourself so we can make sure you are grouped together. Please list ages of children under 18.
*
Any dietary needs?
Please share any copay assistance issues.
How do you receive your primary insurance?
Please Select
Work
Marketplace / Individual
Medicaid
Medicare
Uninsured
Please share any experiences and/or concerns with Marketplace insurance.
Please share any concerns for Medicaid work requirements.
Do you have any close personal relationships with state legislators?
Do you have any additional questions or things we should know as we plan the Statehouse Day?
Submit
Should be Empty: