Contact Info

Your first and last name:   

Your email address:   
please be sure there are no blank spaces before or after your email address
  

Your HTC's Dosage Recommendations

view format example

Hemophilia A routine dose:    units x kg.

Hemophilia A major dose:    units x kg.

Hemophilia B routine dose:    units x kg.

Hemophilia B major dose:    units x kg.
  

Your HTC's
Name and Address

view format example

HTC Name:

This facility treats:     Children    Adults    Both

HTC Address (line 1):

HTC Address (line 2 - optional):

HTC Address (line 3 - optional):

City:

State:      Zip:

Phone:      Fax:
  

Your HTC's
Staff Contact Info

view format example

Name:

 
Title:      
 
Phone:

Name:

 
Title:      
 
Phone:

Name:

 
Title:      
 
Phone:

Name:

 
Title:      
 
Phone:

Name:

 
Title:      
 
Phone:

Name:

 
Title:      
 
Phone:

Night and Weekend Instructions:

 
Phone:
 
Pager:
 

Your HTC's
Special Instructions

view format example

Special Instructions:
  

Patient Wallet Cards

view sample cards

These plastic cards are available free-of-charge and can be distributed
to your patients. Patients, in turn, can use the cards to help direct
medical personnel to the web site when seeking care away from your HTC.