Join Us Test Posted byLoren Vandegrift February 11, 2021February 23, 2021 Leave a comment on Join Us Test Register with Cure HHT This form is accessed through the link only, which will be provided on the Welcome Series emails as well as distributed when we would like to collect more info about a person. Name* First Last Gender*FemaleMaleOtherDate of Birth MM slash DD slash YYYY Preferred Phone Type*HomeWorkMobileOtherHome Phone*Work Phone*Mobile Phone*Other Phone*Preferred Email Type*PersonalWorkAlternatePersonal Email* Work Email* Alternate Email* Preferred Mailing Address Type*HomeWorkOtherAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country How are you connected to HHT? Select all that apply to you:*I have HHTMy spouse has HHTMy child has HHTA friend has HHTI have relatives with HHTI am a physician who treats HHTI am a healthcare provider (non-MD) who works with HHTI have no connection to HHTPrefer not to answerI am a caregiverI have family with HHTI am a health care professional (Non-MD)If you have HHT, please select all that apply to you:Clinically Diagnosed with HHTGenetic Diagnosis with HHTI had genetic testing but inconclusiveI have family members diagnosed with HHT and I have symptomsNot tested/not sureDate of Diagnosis MM slash DD slash YYYY If you have been genetically diagnosed, which gene mutation was identified?Select MutationHHT SMAD 4 Juvenile PolyposisHHT Type 1 - ENGHHT Type 2 - ALK1Inconclusive ResultsHave you visited an HHT Center of Excellence?YesNoWhich Centers have you visited? Select all that apply:AL - Univ of Alabama at Birmingham - UNOFFICIALAR - Univ of Arkansas Medical SciencesAZ - Barrow Neurological InstituteAZ - Mayo Clinic - UNOFFICIALCAN - Edmonton ABCAN - Montreal QCCAN - Toronto ONCAN - Vancouver BC - UNOFFICIALCAN - Winnipeg MBCA - Stanford Hospital and ClinicsCA - Univ of California Los AngelesCA - Univ of California San DiegoCA - Univ of California San FranciscoCO - Univ of Colorado HospitalCT - Yale Univ School of MedicineDC - Medstar Georgetown Univ Hospital - UNOFFICIALFL - UF HealthFL - University of MiamiGA - Augusta UnivIL - Univ of Chicago MedicineIN - Indiana HTCMA - Mass Gen Hospital BostonMD - Johns Hopkins UnivMI - Univ of Michigan HTC - UNOFFICIALMN - Mayo ClinicMO - Wash U St. LouisNC - UNC Chapel HillNY - Albany Univ ENT - UNOFFICIALNY - Lenox Hill Hospital - UNOFFICIALNY - NY Presbyterian / CUMCOH - Cincinnati Children's HospitalOH - Cleveland ClinicOR - Pacific Northwest HHT COEOther Not ListedPA - Univ of PennsylvaniaPA - UPMC and The Univ of PittsburghTX - Texas Children's HospitalTX - Univ of Texas SouthwesternUT - Univ of UtahVA - Univ of Virginia - UNOFFICIALWA - Seattle Children's Hospital - UNOFFICIALWI - Froedtert and Medical College of WisconsinWhich of your family members are affected? Select all that apply:MotherFatherSisterBrotherGrandmotherGrandfatherAunt / UncleNiece / NephewCousinIn-lawHusbandWifeSonDaughterIf you have HHT, how are you affected? Select all that apply to you:AnemiaBlood ClotBrain AbscessBrain AVMGI BleedingHeart FailureIron DeficiencyKidney BleedingLiver AVMLiver DiseaseLow OxygenLung AVMLung HemorrhageMigrainesNosebleedsPulmonary HypertensionSeizuresSkin TelangiectasiaStrokeUterine HemorrhageIf you have HHT, what treatments have you received? Select all that apply.Blood TransfusionCauteryCoblationCoblation - GICoblation - NoseDrug TherapyDrug Therapy - Avastin InjectionDrug Therapy - Avastin IVDrug Therapy - DoxycylineDrug Therapy - PazopanibDrug Therapy - PomalidomideEmbolizationIron Therapy - IVIron Therapy - OralLiver TransplantLung TransplantMedical TreatmentNosebleed - LaserNosebleed - Medical TreatmentNosebleed - SclerotherapyNosebleed - SurgerySurgeryAre you interested in participating in HHT research?YesNoNot sure but I'd like more informationHow did you hear about Cure HHT?FamilyWeb searchPhysicianLiteratureOtherNot sure/don't rememberIs this your first time contacting Cure HHT?YesNoWhat information/topics would you like to hear about from Cure HHT?HHT News & AnnouncementsHHT EventsHHT Medical & Research UpdatesHHT EducationHHT Resources for AdultsHHT Resources for ChildrenLocal HHT Community ActivitiesLegislative & Advocacy OpportunitiesResearch Study Participation OpportunitiesHHT Volunteer OpportunitiesBlog/Living with HHTHow would you like to hear from us?EmailPostal MailPhoneAll of the aboveDo not contact me with updatesCure HHT may use the information you have provided on this form to contact you with updates. Please let us know the ways you would like to hear from us. You can change your mind at any time by clicking the unsubscribe link in the footer of any email you receive from us or by contacting us at (410) 357-9932 or emailing [email protected]Privacy Consent*The information provided on this form will be stored by Cure HHT and used to provide our constituents with information and updates that better align with their needs and interests.We will treat your information with respect. For more information about our privacy practices please visit www.curehht.org. By clicking below, you agree that we may process your information in accordance with the terms of our privacy policy. Consent required for submission. By completing this form, I consent to having Cure HHT store my submitted information so they may provide me with information and updates that align with my needs and interests. HiddenConsent to Store/Use Data Gives Consent to Cure HHT to Store/Use Data Complimentary booklet?* Yes, I would like to be mailed a complimentary copy of "A Comprehensive Guide to Managing Your HHT". HiddenLead SourceAwareness VideoBLEVINSBoard DirectorCDCCFC DonorConference - PatientConference - ScientificConstant Contact Email CampaignContinuing EducationDeb DrysdaleDentistDiscovery Health ProgramE Commerce/ purchaseEmailEmployee Giving Program DonorFacebookFamilyFriendFundraisingGlobal Research Medical Advisory BoardHealthcare ProfessionalHemophilia Thrombosis CenterHHT AppHHT CenterJoin Us FormMeetingMemorialPatientPayPalPhysicianPhysician DirectoryPress and MediaResearchSchool NurseStory SubmissionSurveyTributeWebWebinarWebsiteJOIN our Cure HHT Community! Let us know who you are. At Cure HHT, whether you are diagnosed with HHT, are a family member of an individual diagnosed with HHT, a medical professional, caregiver, or simply someone interested in HHT, we care about you as an individual! Join now as a valued member of our community, so that we can ensure that you receive all of the information and resources useful to you. Simply indicate the information you wish to receive below. HiddenSFID Δ