Patient Registration

Register for Information

U.S. Patient Registration Form

Fields marked with an * are required

Patient: First Name *
Patient: Last Name *
Patient: Sex *
Patient: Date of Birth *
If under age of 18, name of parent or legal guardian
Email *
Address *
City *
State *
Zip *
Phone *
Thalassemia Diagnosis *
Ethnicity
Primary Thalassemia Care Provider *
Hospital or clinic you receive regular thalassemia care
Provider: Address:
Provider: Email:
Provider: Phone:
How often are you transfused? *
How many units do you typically receive when you get transfused? *
Which chelator(s) are you prescribed? *
How many days are you chelating? *
How did you hear about us?
Consent *
The information gathered on this form will enable the Cooley's Anemia Foundation to stay in touch with you and to better understand the needs of the Thalassemia community. This information will not be shared with outside sources.

Why your support
is literally
our lifeblood

For over 70 years, the Cooley's Anemia Foundation, a 501(c)(3) nonprofit organization, has been a strong and supportive partner for families living with Thalassemia.

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