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• * Salutation: Dr. Mr. Mrs. Ms.
• * First Name:
• * Last Name:
• * I Am a: Patient Caregiver Healthcare Professional Other

• * This Is My: Home Address
  Work Address
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• *My key area of interest is (check all that apply): Hemophilia A
  Hemophilia B
  von Willebrand disease
• I would like to receive a reusable infusion mat to use when mixing Humate-P®. Please note: This offer is limited to one infusion mat per request on Web site.

• Educational Materials

  I would like the following educational materials sent to me. (If you would like to request additional quantities, please contact Consumer Affairs at 1-888-508-6978.)
• Introducing You to VWD and Humate-P®—This brochure offers newly diagnosed patients help in managing their condition while providing important information about Humate-P® as a treatment option.
  Humate-P® Consumer Brochure—For patients who want a more in-depth look at Humate-P®, this brochure discusses high molecular weight multimers, the viral safety of Humate-P®, and the clot formation process.
  Patient's Guide to Understanding VWD—This booklet talks about the disorder, symptoms, and diagnosis, and provides general information on treatment options.
  VWD, Menstruation, and Your Daughter—Women with VWD may experience menorrhagia during menstruation, and this booklet helps parents explain to their pre-teen daughters how VWD may affect them.