Membership Application Form

Hemophilia Foundation of Maryland Membership Application

Membership is FREE. Please complete the form below so we may best serve you. All new members will receive a new member welcome package. To learn more about HFM, visit www.hfmonline.org.
Patient's Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Date of Birth*
Home Number*

Area CodePhone Number
Cellular Number*

Area CodePhone Number
Work Number

Area CodePhone Number
If patient is a minor, please enter Parents Names:
Patient's Diagnosis*

Severe Hemophilia ASevere Hemophilia BModerate Hemophilia AModerate Hemophilia BMild Hemophilia AMild Hemophilia BvonWillebrand Disease Type 1Platelet DisordervonWillebrand Disease Type 2vonWillebrand Disease Type 3Other
Name of Specialty Pharmacy (where you get your bleeding disorder medication filled):*
Name of Hematologist or HTC*
By selecting Apply for Membership below, I confirm that I am an individual with a congential bleeding disorder or a parent of a person with a bleeding disorder. I certify that the information included on this application is true and correct. I authorize this release of information to the Hemophilia Foundation of Maryland in order to verify all statements made in this application. I also give permission to contact a representative at my local hemophilia treatment center or hemotologist office as necessary to confirm diagnosis.
How did you hear about the Hemophilia Foundation of Maryland*
Signature*

Clear
Name of person completing this form:*

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Hemophilia Foundation of Maryland Membership Application