aHUS Genetic Testing Sponsorship Enrollment HomeaHUS Genetic Testing Sponsorship Enrollment aHUS Genetic Testing Sponsorship Enrollment Intake Who is completing this form? (Samples submitted by patients completing this form will not be processed.)* Healthcare Provider (HCP) Is this patient currently an inpatient?* NoYes Hospital lab phone Patient First Name* Last Name* Middle Initial Date of Birth* Gender at Birth* MaleFemaleOther Ethnicity EuropeanAfricanLatinoEast AsianSouth AsianOtherPrefer not to answer Address Line 1* Address Line 2 City* State* Zip Code* Phone* Email* Physician First Name* Last Name* Middle Initial NPI# Type* hematologist/oncologistnephrologistpathologistrheumatologistother Hospital Association Clinical Setting* Private PracticeCommunity HospitalAcademic CenterClinic City* State* Zip Code* Phone* Email Fax Other What is the ICD-10 code associated with this patient?* D59.39Other Has TTP been ruled out by testing an ADAMTS13 activity?* Yes, ADAMTS13 activity is > 10%No, ADAMTS13 activity result is pendingADAMTS13 activity test not ordered ADAMTS13 Activity* Has the patient been tested for aHUS genetics previously?* YesNo Has the patient received a bone marrow transplant?* YesNo Does the ordering physician acknowledge that some de-identified patient and de-identified physician information will be shared with the program sponsor?* YesNo Does the ordering physician agree to be surveyed on their use of the program?* YesNo What is the ordering physician's preferred method of receiving the results?* EmailFaxPhone How did you hear about this program?* EmailColleagueWeb SearchAlexion RepOther Do you commit not to bill third parties for this testing?* YesNo Quality Assurance: Can Machaon check in with you after you receive the result to ensure everything went smoothly?* YesNo Would you like to be contacted to schedule a clinical consultation as part of this patient enrollment?* YesNo Is the ordering physician's primary practice in one of these states?* CaliforniaTexasNew YorkFloridaNo When do you typically assess your aHUS patient’s long-term prognosis?* At diagnosisAt treatment startAt 3 months of treatmentAt 6 months of treatmentWhen considering treatment change or discontinuation after more than 6 monthsOther If you are not using genetic testing or using it in less than 50% of aHUS cases, why have you not used it more?* I never had positive genetic testing results for an aHUS patientGenetic testing results are often inconclusive or difficult to interpret in my opinionGenetic testing results typically do not change my treatment decisionsPatients not consentingRisk with insurance/payers denying treatmentOther Are you typically using genetic consultation services provided by the laboratory when requesting genetic testing, either before or after the test?* NeverSometimesOftenAlways By submitting this form, you consent to sharing some data with Machaon Diagnostics and Alexion Pharmaceuticals.