Ethnic Group
Please select your ethnic group from the list. You can hold "Ctrl" on your keyboard to select more than one item on the list. White English / Welsh / Scottish / Northern Irish / British White Irish White Gypsy or Irish Traveller White European Any other White background White and Black Caribbean White and Black African White and Asian Any other Mixed / Multiple ethnic background Indian Pakistani Bangladeshi Chinese Any other Asian background African Caribbean Any other Black / African / Caribbean background Arab Any other ethnic group Prefer not to say
I Prefer to Speak...
Please select one or more of the following statements that best describes you. You can hold "Ctrl" on your keyboard to select more than one item on the list. English Albanian Arabic Bengali Bulgarian Czech Danish Dutch Estonian Finnish French Greek Gujarati Hindi Hungarian Italian German Kurdish Latvian Lithuanian Maltese Persian Polish Portuguese Punjabi Romanian Russian Slovenian Somali Spanish Swedish Tamil Turkish Urdu Ukrainian Other Prefer not to say
Nationality Group
Please select your nationality from the list. Afghan Albanian Algerian American Andorran Angolan Anguillan Citizen of Antigua and Barbuda Argentine Armenian Australian Austrian Azerbaijani Bahamian Bahraini Bangladeshi Barbadian Belarusian Belgian Belizean Beninese Bermudian Bhutanese Bolivian Citizen of Bosnia and Herzegovina Botswana Brazilian British British Virgin Islander Bruneian Bulgarian Burkinan Burmese Burundian Cambodian Cameroonian Canadian Cape Verdean Cayman Islander Central African Chadian Chilean Chinese Colombian Comoran Congolese(Congo) Congolese (DRC) Cook Islander Costa Rican Croatian Cuban Cymraes Cymro Cypriot Czech Danish Djiboutian Dominican Citizen of the Dominican Republic Dutch East Timorese Ecuadorean Egyptian Emirati English Equatorial Guinean Eritrean Estonian Ethiopian Faroese Fijian Filipino Finnish French Gabonese Gambian Georgian German Ghanaian Gibraltarian Greek Greenlandic Grenadian Guamanian Guatemalan Citizen of Guinea-Bissau Guinean Guyanese Haitian Honduran Hong Konger Hungarian Icelandic Indian Iranian Iraqi Irish Israeli Italian Ivorian Jamaican Japanese Jordanian Kazakh Kenyan Kittitian Citizen of Kiribati Kosovan Kuwaiti Kyrgyz Lao Latvian Lebanese Liberian Libyan Liechtenstein citizen Lithuanian Luxembourger Macanese Macedonian Malagasy Malawian Malaysian Maldivian Malian Maltese Marshallese Martiniquais Mauritanian Mauritian Mexican Micronesian Moldovan Monegasque Mongolian Montenegrin Montserratian Moroccan Mosotho Mozambican Namibian Nauruan Nepalese New Zealander Nicaraguan Nigerian Nigerien Niuean North Korean Northern Irish Norwegian Omani Pakistani Palauan Palestinian Panamanian Papua New Guinean Paraguayan Peruvian Pitcairn Islander Polish Portuguese Prydeinig Puerto Rican Qatari Romanian Russian Rwandan Salvadorean Sammarinese Samoan Sao Tomean Saudi Arabian Scottish Senegalese Serbian Citizen of Seychelles Sierra Leonean Singaporean Slovak Slovenian Solomon Islander Somali South African South Korean South Sudanese Spanish Sri Lankan St Helenian St Lucian Stateless Sudanese Surinamese Swazi Swedish Swiss Syrian Taiwanese Tajik Tanzanian Thai Togolese Tongan Trinidadian Tristanian Tunisian Turkish Turkmen Turks and Caicos Islander Tuvaluan Ugandan Ukrainian Uruguayan Uzbek Vatican citizen Citizen of Vanuatu Venezuelan Vietnamese Vincentian Wallisian Welsh Yemeni Zambian Zimbabwean Prefer not to say
Your Contact Details
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Your Bleeding Disorders
Relevant bleeding disorder(s)
Please let us know which bleeding disorder is relevant to you. You can hold "Ctrl" on your keyboard to select more than one item on the list. Haemophilia A Haemophilia B Carrier (unaffected) von Willebrand type 1 von Willebrand type 2A von Willebrand type 2B von Willebrand type 2M von Willebrand type 2N von Willebrand type 3 von Willebrand type unspecified von Willebrand type unreported Factor V Deficiency Factor VII Deficiency Factor X Deficiency Factor XI Deficiency Factor XIII Deficiency Combined II+VII+IX+X Deficiency Combined V+VIII Deficiency Prothrombin (Factor II) Deficiency Afibrinogenemia Dysfibrinogenemia Hypofibrinogenemia Hypodysfibrinogenemia Fibrinogen Deficiency Other severe platelet disorder Bernard Soulier Glanzmann’s Thrombasthenia Other Platelet Disorder Bleeding Disorder Unknown Cause (BDUC) No bleeding disorder
Haemophilia Centre
Which Haemophilia centre are you associated with? —Please choose an option— Aberdeen – Royal Infirmary (HC) Barnstaple – North Devon District Hospital (HC) Belfast – City Hospital (CCC) Belfast – Hospital For Sick Children (CCC) Birmingham – Children’s Hospital (CCC) Birmingham – Queen Elizabeth (CCC) Bournemouth/Poole – Royal Bournemouth (HC) Bradford – Royal Infirmary (HC) Bristol – Bristol Royal Infirmary (CCC) Bristol - Bristol Royal Hospital for Children (CCC) Cambridge – Addenbrookes Hospital (CCC) Canterbury – Kent & Canterbury Hospital (CCC) Cardiff – University Hospital of Wales (CCC) Coventry - University Hospitals (HC) Derby – University Hospitals (HC) Dundee – University Hospitals (HC) Eastbourne – District General Hospital (HC) Edinburgh – Royal Infirmary (CCC) Glasgow – Royal Hospital for Sick Children (CCC) Glasgow – Royal Infirmary (CCC) Hampshire – Basingstoke & North Hampshire Hospital (CCC) Hull – Castle Hill Hospital (HC) Inverness – Raigmore Hospital (HC) Jersey – General Hospital Lancaster – Royal Lancaster Infirmary (HC) Leeds – Children’s Hospital (CCC) Leeds – St. James’s University (CCC) Leicester – Royal Infirmary (CCC) Lincoln – County Hospital (HC) Liverpool – Alder Hey Children’s Hospital (CCC) Liverpool – Royal Liverpool Hospital (CCC) London – Evelina Children’s Hospital (CCC) London – Great Ormond Street Children’s Hospital (CCC) London – Hammersmith Hospital (HC) London – Royal Free Hospital (CCC) London – Royal London Hospital (CCC) London – St Thomas’ and Guys Hospital (CCC) London – University Hospital Lewisham (HC) London – St. Georges Hospital (HC) Manchester – Royal Infirmary (CCC) Manchester – Royal Manchester Children’s Hospital (CCC) Newcastle - Royal Victory Infirmary (CCC) North Staffs – Royal Stoke University Hospital (HC) Norwich – Norfolk and Norwich (HC) Nottingham – QMC University Hospital (CCC) Other (not CCC or HC) Overseas Hospital (Member – no voting right) Oxford – Churchill Hospital (CCC) Oxford – John Radcliffe Children (CCC) Peterborough – City Hospital (HC) Plymouth – Derriford Hospital (HC) Portsmouth – Queen Alexandra Hospital (HC) Sheffield – Children’s Hospital (CCC) Sheffield – Royal Hallamshire Hospital (CCC) Shrewsbury & Telford – Shrewsbury Hospital (HC) Southampton – University Hospital (CCC) Swansea – Singleton Hospital (HC) Taunton / Yeovil – Musgrove Park Hospital (HC) Torquay / Torbay – Torbay Hospital (HC) Truro – Royal Cornwall Hospital (HC) Unknown – not given N/A
Children and Young People (Under 18)
If you’re a parent/guardian of any children or young people under the age of 18, please provide us with their details below – including any siblings who don’t have a bleeding disorder. Providing us with this information will help us to send you relevant information to your child’s age-group and to let you know about children’s and young people’s activities and events they might like to take part in.
Communication Preferences
As a member you consent to receive information regarding our work, through HQ magazine, online and newsletters. As a member, we are required to contact you with statutory information such as AGM papers and member voting information as part of our constitution. If there are any specific areas of interest you would like more information about, we would want to make sure you get it. It is key for us that we can serve you as best as possible, tailoring information to your interests.
I would like to:
"Hear more about your campaigning work. For example - updates on benefits, advocacy, access to treatment, quality of care etc." "Hear how people support The Society and about the ways funding is raised to provide the free services to the community." "Receive the latest information about services, and ways The Society supports the community." "Be kept updated about the work being done on the Public Inquiry."]
The Haemophilia Society would like to keep you up to date with our work including information about our support, services and events for families and young people, details of fundraising activities, volunteering, general information about our work and what you are helping us to achieve. We need your permission to keep in touch, we will keep your details safe and you can change your preferences at any time by contacting us. Please read our Privacy Policy for more information about how we look after your details. Please tick how you would like the Haemophilia Society to contact you in the future. As a member, you can vote in our Trustee elections and will receive information about this. You will also receive our Community Matters magazine and appeals twice a year by your preferred choice of communication as part of your membership.
Communication preference: (select at least one option)
Email Post
Disclaimer: You will be automatically opted-in to receive our communications. If you wish to opt out, please confirm your preferences below:
I do not want to receive information on:
Hear The Latest News (eNews) Services and Events (information on how to get involved with our work) Support On Raising Money For Us (Fundraising) Infected Blood Public Inquiry
Please note: Due to increasing postal charges, we do not post all fundraising, public inquiry, and services communications. All information can be found on our website.
Email is the most efficient way that we can keep in touch with you. We promise that we will not inundate you with information.
Please keep us up to date with your contact details if they change, and remember to add our email address to your Safe Senders list so you'll always receive our messages in your inbox.
Make a Monthly Donation
We rely on voluntary donations to support our work for everyone with a genetic bleeding disorder. Monthly donations, big or small, are vital in helping us plan for the future so that we can always be there for our community.
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