NENHF Consent to Contact Form

By completing this form, you are authorizing The University of Nebraska Medical Center Hemophilia Treatment Center and/or Children’s Hospital to release your contact information to NENHF and to be added to our mail and email correspondence lists. NENHF will contact you by phone or email in order to obtain any additional information that may be relevant for determining program interest and eligibility. Your participation is completely voluntary and can be withdrawn at any time upon your request. Your information will not be used for any other purpose or released to any other parties. 

Household Information
First Name
Last Name
Address
Address Line 1
City
State
Country
Phone Number
Email
Please select your age range
Patient Diagnosis
If Other please specify
NENHF measures it's success by its programs. Please indicate your FAMILIES areas of interest:

Please list all members of your household so we can best serve the needs of your family. (Required) 

Indicate individuals name, DOB, Status (affected, caregiver, sibling etc.) bleeding disorder type, and severity:

WE WELCOME YOU!

NENHF provides programming, education, and resources for those that are affected by genetic and chronic bleeding disorders. Our vision is to create an environment where you are part of a community, part of the solution, and have access to the information you need to make informed decisions. The chapter provides low cost and free opportunities throughout Nebraska to create connections and allow a comprehensive understanding of available resources. Your participation is the most valuable part of our organization.

8031 West Center Road
Suite 304
Omaha, NE 68124

© National Hemophilia Foundation - Nebraska Chapter 2022

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