Hemophilia Council of California- HEALTHCARE ACCESS ISSUE REPORT FOR PATIENTS WITH BLEEDING DISORDERS

Privacy Notice: Your identity will not be disclosed to any other individuals, groups or organizations outside of HCC without your express written permission.
Sign in to Google to save your progress. Learn more
Patient Name (optional)
Patient’s county of residence
 Age
Gender
Clear selection
Bleeding disorder:
Clear selection
Type of insurance:
Clear selection
Who is completing this report?
Clear selection
Name of medical facility where problem occurred (optional)
Physician name (optional)
What is the best way to communicate with you if more information is needed? (optional)
Clear selection
Email or Phone Contact Information (optional):
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Hemophilia Council of California. Report Abuse