Institute/Department: 

Responsible Dr/Prof:   


E-mail          

City              

Country        

Phone                 

Fax               

Have you any experience with Menorrhagia?  yes no

If yes, please specify how many patients are registered in you Center:  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18 19 20 21 22 23 24 25

Have you already registered your patients
in a National or International database on Rare Coagulation disorders?  yes no

If yes please report your registry: 

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