ACARE Application for UCARE Centers

Center information

Center name(Required)

This information will be public

Clinic name

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Center address(Required)

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Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Center email(Required)

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Center phone

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Center website

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Department information

Department email address

This information will not be public

Department phone

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Department mail address

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Department head

Head of department name

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Head of department email address

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Department deputy

Department deputy name

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Department deputy email address

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Application

Dear Professor Maurer,

Our center is a UCARE, and we would like to make use of the priviledged access protocol for UCAREs to join the GA²LEN/HAEi Angioedema Centers of Reference and Excellence (ACARE) network. We apply for our center to become an ACARE.

Please note: Some of the information listed above (including the center’s name and address, contact information for patients, website and logo) may be published on the UCARE website. You can find examples of our centers' profiles on the "Centers" tab of the UCARE website: https://ga2len-ucare.com/centers/

Verify information

Please verify your information before submitting your application. If you need to change your submitted information, click "Previous" at the bottom of this page to go back

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Applicant name(Required)

Applicant email(Required)

Application date(Required)

Applicant signature(Required)