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I am a: Select Role... Person With a Bleeding Disorder Parent Supporter (eg spouse, friend) Other Healthcare Provider Please choose one.

Specialty:

Hematologist Hematologist/Oncologist Obstetrician/Gynecologist Primary Care Nurse Practitioner Clinician Pharmacist Other Healthcare Professional Please select your specialty.

Supporter Information:

Spouse/Significant other/Partner Primary Caregiver Family Member Friend Other Supporter Date of Birth: Please enter date of birth in the following format: MM/DD/YYYY.

Type of Bleeding Disorder:

Hemophilia B (Factor IX Deficiency) Please select Type of Bleeding Disorder.

Child's information

Child's Date of Birth:

Type of Bleeding Disorder:

Hemophilia B (Factor IX Deficiency) Please select Type of Bleeding Disorder.

Add Child +

Second Child's information

Child's Date of Birth:

Type of Bleeding Disorder:

Hemophilia B (Factor IX Deficiency) Please select Type of Bleeding Disorder.

Remove Child -

First Name: Please enter your first name. Last Name: Please enter your last name. Email Address: Please enter a valid email address. ZIP Code: Please enter your ZIP code.

Mobile Phone Number (Optional): Please enter a valid phone number. Street Address (Optional): Street Address 2 (Optional): City (Optional): State (Optional): Select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Answering the following questions will allow us to send materials that better match your interests.

1. Describe the setting in which you practice (Optional): Select Answer... Select Answer... HTC Hospital Urgent Care Private Practice ER Other Other: 2. What type of information would you like to receive from Takeda? (check all that apply) (Optional) Patient support information Clinical resources Product information Other 3. How many patients with Hemophilia B do you treat in a regular month? (Optional) Select Answer... Select Answer... 0-2 patients 3-5 patients More than 5 patients

Answering the following questions will allow us to send materials that better match your interests.

1. Name of treatment (Optional): Select Treatment... Select Treatment... RIXUBIS Unknown Other None Other: 2. How long ago were youwas the patient diagnosed with a bleeding disorder? (Optional) Select Answer... Select Answer... 1-5 years 6-10 years 11-20 years 21-30 years 31+ years 3. How often do youdoes the patient visit the emergency room for uncontrolled bleeds? (Optional) Select Answer... Select Answer... Less than once a month Once a month Once every 3 months Once every 6 months More than every 6 months 4. What type of information would you like to receive from Takeda? (Check all that apply) (Optional) Disease state information Doctor discussion guide Starter kit Product information Community connections Lifestyle content Live events Text/SMS reminders