World Health Organization Collaborating Center for Inherited Bleeding Disorders

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"ANGELO BIANCHI BONOMI" HEMOPHILIA AND THROMBOSIS CENTER
IRCCS MAGGIORE HOSPITAL, MANGIAGALLI AND REGINA ELENA FOUNDATION
"LUIGI VILLA" FOUNDATION
DEPARTMENT OF MEDICINE AND MEDICAL SPECIALITIES, UNIVERSITY OF MILAN

Via Pace, 9 – 20122 MILAN, ITALY

International Registry of Rare Bleeding Disorders

JOINING FORM

Ph. +39 02 54125707, Fax +39 02 54100125, E-mail: join@rbdd.org

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CENTER DATA:

Institute/Department:

Responsible Dr/Prof E-mail

City Country

Phone Fax

Have you any experience with Rare Bleeding Disorders? yes no

If yes, please specify how many patients are registered in you Center:

FACTOR	NUMBER OF PROBANDS
Afibrinogenaemia
Factor II
Factor V
Factor V+VIII
Factor VII
Factor X
Factor XI
Factor XIII
Factor VII+X
Factor V+VII
other combined deficiencies please specify:

Please specify the type of treatment that you usually use in your Center

FACTOR	NAME OF PRODUCTS
Afibrinogenaemia
Factor II
Factor V
Factor V+VIII
Factor VII
Factor X
Factor XI
Factor XIII
Factor VII+X
Factor V+VII
other combined deficiencies please specify:

Could you please specify if you had any problem during the treatment of your patients?
Due to:

•  Inability to get desired product:

•  Cost of the product:

•  No factor concentrate available:

•  Adverse effects:

•  Other:

Have you already registered your patients in a National or International database on Rare Coagulation disorders? yes no

If yes please report your registry:

authorization (privacy policy)