Physician Registry
Hereditary Antithrombin Deficiency (HD)

• Identify physicians who occasionally treat HD patients
• Understand the population distribution patterns of this defect
• Discuss participation in future clinical trials and related research
• Keep the medical community informed of our research progress
• Receive invitations to GTC sponsored seminars and symposia

Your Contact Data

Name
Title
Address
City
State/Province	Zip
Country
Email Address
Tel Country Code	Area/City Code:
Tel Number
Clinical Specialty

Your Patients

1. What is the total number of patients with confirmed Hereditary Antithrombin Deficiency (AT HD) that you see per year?

2. How many confirmed new diagnoses of AT HD have you identified in: The last year?   The last 5 years?

3. What is the total number of patients with confirmed AT HD that you have access to for performing a clinical study at your institution with recombinant human antithrombin?

4. What is the estimated number of high risk events (child birth, surgery) involving AT HD patients that you are directly aware of in an average year?

5. How many patients with confirmed AT HD do you think there are in your general area?

6. Have you ever used antithrombin in high-risk cases involving AT HD patients? No Yes

7. How quickly can you receive a patient's antithrombin serum activity level from your hospital's lab? Please select one: 2 hours or less 2 - 6 hours 6 - 12 hours one day or more can't do it

Your Colleagues

May we ask you to recommend physicians or medical centers in the United States or Europe with known HD populations who treat heditary AT deficient patients?
Name		Name
Institution		Institution
City		City
Country		Country

May we contact you again to discuss this information, or possible participation in an AT HD clinical trial?

No Yes