Member Registration Form

Name*
Prefix First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Gender*
Member Type*
HAE Type*
Date of Birth*
DD slash MM slash YYYY
Phone - Home
Phone - Mobile*
Prophylactic treatment
Acute treatment
Treating hospital*
HAE consultant name*
HAE consultant phone
HAE consultant email
Interested in clinical trials?*
- Yes
- No
Emergency contact name
Prefix First Last
Emergency contact phone

By becoming a member of HAE UK, you agree to us holding the above information about you on our secure GDPR compliant database, HAEi Connect. You can request to update your information or to have your information deleted from our database at any time. Please e-mail: support@haeuk.org