Membership Form Please note: Kindly note that only ONE registration will be accepted per HTC. Please discuss with your team before submit the form.Name Address State Email ID of the HTC Phone No Name of the Director/HTC In-Charge Email ID Phone No Total number of patients with a Hereditary Bleeding Disorder registered at the centre Total number of patients with a Hereditary Bleeding Disorder on regular annual follow up Bleeding DisorderHaemophilia A Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Haemophilia B Patients Registered Patients with Annual Follow-Up Patients with Severe Disease VWD Type 1 Patients Registered Patients with Annual Follow-Up Patients with Severe Disease VWD Type 2 Patients Registered Patients with Annual Follow-Up Patients with Severe Disease VWD Type 3 Patients Registered Patients with Annual Follow-Up Patients with Severe Disease VWD Type Unknown Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Afibrinogenemia (<10mg/dl) Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Hypofibrinogenemia (50-150mg/dl) Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Dysfibrinogenemia (10-50mg/dl) Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Factor II Deficiency Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Factor V Deficiency Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Factor VII Deficiency Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Factor X Deficiency Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Factor XI Deficiency Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Factor XIII Deficiency Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Combined Factor V + VIII Deficiency Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Combined Factor II + VII + IX + X Deficiency Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Glanzmann’s thrombasthenia Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Bernard Soulier Syndrome Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Others Patients Registered Patients with Annual Follow-Up Patients with Severe Disease Haemophilia Treatment Center - Comprehensive Team members details. (Members can be added every year. Member List to be updated every year) MEMBERSPhysician Name (Full name with initials) E-mail address Name (Full name with initials) E-mail address Name (Full name with initials) E-mail address Pathologist Name (Full name with initials) E-mail address Name (Full name with initials) E-mail address Nurse Coordinator Name (Full name with initials) E-mail address Name (Full name with initials) E-mail address Physiotherapist Name (Full name with initials) E-mail address Name (Full name with initials) E-mail address Orthopaedic Surgeon Name (Full name with initials) E-mail address Name (Full name with initials) E-mail address Other Surgeons Name (Full name with initials) E-mail address Name (Full name with initials) E-mail address Laboratory Scientists Name (Full name with initials) E-mail address Name (Full name with initials) E-mail address Data Manager Name (Full name with initials) E-mail address Name (Full name with initials) E-mail address Psycho-Social Team Name (Full name with initials) E-mail address Name (Full name with initials) E-mail address Coordinator Name (Full name with initials) E-mail address Name (Full name with initials) E-mail address Other Name (Full name with initials) E-mail address Name (Full name with initials) E-mail address ** Each Category can have multiple names. ***Leave it blank if not available Consent: I agree to register our HTC as an Institutional Member of IAHAD. I hereby declare that the entries made in this form as above is true and correct to the best of my knowledge and belief. Signature - Head / Physician In-charge of HTCName Signature VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
