Join HFM - The Hemophilia Foundation of Maryland

Join HFM

The Hemophilia Foundation of Maryland is here to assist persons with hemophilia and/or related bleeding disorders within the state of Maryland and surrounding areas.

Learn who we serve: CLICK HERE

Name of Patient

If Patient is a Minor

Email Address

Phone Number

Street Address

Street Address 2

City

State

Zip Code

Why are you interested in Bleeding Disorders?

What is your experience with Bleeding Disorders?

What specific interests do you have in joining HFM?

Do you have Hemophilia A?

Do you have Hemophilia B?

Do you have vonWillebrand Disorder?

Do you have a Platelet Disorder?

Do you have another Bleeding Disorder or Condition?

Who is your doctor and the HTC Affiliation (i.e., Hopkins, Georgetown, Children's, etc):

Name of Specialty Pharmacy (where you get your bleeding disorder medication filled):

I give my permission to list my name and contact information to the HFM Support Group. I also give HFM permission to photograph members who attend our events and programs for the purpose of promoting HFM through media and communications. I understand my information will not be provided, sold or distributed to any other organization, cooperation or industry/healthcare provider.

By submitting this membership request, I confirm that I am an individual with a congenital bleeding disorder or 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.

Learn who we serve: CLICK HERE

Hemophilia Foundation of Maryland (HFM)

13 Class Court Parkville, MD 21234

We are here to help

Get Help Now

(410) 661-2307

The Hemophilia Foundation of Maryland

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