Ad Board Opportunity
We have a paid opportunity for adult patients (as well as parents/caregivers of someone) with HEMOPHILIA A or B with an INHIBITOR. Chosen participants are required to attend a consumer council meeting onsite, in Dallas, TX (travel included.) But availability is limited, so those interested should apply without delay.
Are you applying for yourself or for your child?
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Myself
My child, who will be under age 18 on/after 8/7/2026
Your Name
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First Name
Last Name
Child's Name
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First Name
Last Name
Your Date of Birth
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Month
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Day
Year
Date
Child's Date of Birth
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Month
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Day
Year
Date
I'm someone with an inhibitor and Hemophilia...
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A (FVIIId)
B (FXd)
I'm a caregiver of someone with an Inhibitor and Hemophilia...
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A (FVIIId)
B (FIXd)
Approximately when did you last participate in an Ad Board for HEMA Biologics?
1-2 yrs ago
3-5 yrs ago
More than 5 yrs ago
I've never participated
Medical Info
Click box if this statement is true, otherwise leave blank
Patient cannot receive factor replacement due to risk of anaphylactic reaction.
Most recent Inhibitor/Titer level
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Approx. date Inhibitor/Titer level was taken
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Month
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Day
Year
ABR (Annual Bleed Rate)
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Average number of bleeds per year
Product(s) used to treat bleeds
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Product(s) used for prophy (prohylactic) treatment
Contact Info
Email
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Confirmation Email
Phone Number
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Format: (000) 000-0000.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
By signing below,
I agree to be contacted by 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
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
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