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First Name:
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What Describes You Best:
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Patient
Parent or Family of Patient
Healthcare Provider
Industry Representative
Representative of Patient Organization
Other
Please specify your thalassemia (or red blood cell disorder) condition:
(If parent/family please refer to the patient's condition)
- select -
Transfusion Dependant - Beta Thalassemia Major
Transfusion Dependent - Alpha Thalassemia Major
Hemoglobin H Disorder (HbH)
Hemoglobin E - Beta Thalassemia
Non-Transfusion Dependent Thalassemia
Sickle Cell - Beta Thalassemia
N/A
Which age group describes you
(if parent/guardian please refer to patient's age)?
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Under 12
12-18
19-24
25-34
35-44
45-54
55-65
65+
N/A
Continue / Continuer
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