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Join The Scientific Registry
Research for a Cure

The information you provide will be kept strictly confidential. You must complete all fields in the form to submit it.

First Name: 
Last Name: 
Maiden Name: 
(if applicable)
 
Gender:  Male Female
 
Address: 
 
 
City: 
State:    Zip Code: 
 
Home Phone Number:  Digits only - no spaces, dashes, or parenthesis
Cell Phone Number:  Digits only - no spaces, dashes, or parenthesis
E-mail address: 
Secondary E-mail address: 
 
Date of Birth: 
 
Diagnosis: 
 
Ethnicity: 







 
Are you a member of the US HAE Association?  Yes No
Do you have a blood relative with known HAE?  Yes No
Do you have a blood relative with HAE who is currently participating in this research project?  Yes No
 
What medication(s) do you currently use?








 
Please select one:
   I would like to enroll in the Scientific Registry only. or
   I would like to enroll in the Scientific Registry, and the Ruconest Safety Registry
 



You will be contacted by the Registry Administrator once your Consent Forms are received and reviewed with additional information on how to access the Registry Portal.


Sign Up Today!

Have questions?
Contact Registry Administrator
Sherry Swanson


Sherry
sherryswanson@haea.org

(866) 798 - 5598

US HAEA Scientific Registry
10560 Main Street, Suite PS40
Fairfax City, VA 22030


Scientific Registry