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 Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

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

Area Code Phone Number
Cellular Number *

Area Code Phone Number
Work Number

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

Severe Hemophilia A Severe Hemophilia B Moderate Hemophilia A Moderate Hemophilia B Mild Hemophilia A Mild Hemophilia B von Willebrand Disease Platelet Disorder
Name of Specialty Pharmacy:
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.
Signature *

Clear
Name of person completing this form: *

First Name Last Name
Date

Month Day Year
Date
Should be Empty:

Hemophilia Foundation of Maryland Membership Application