Pharmacy Inquiry Form Please complete the following and an HoG pharmacy staff member will provide more information to you. 1. Case Manager's Name * 2. Case Manager's Company 3. Case Manager's Telephone Number * Please include area code 4. Case Manager's Fax Number 5. Case Manager's Email Address * 6. Patient's Insurance Company * 7. Patient's Diagnosis * --Select--Hemophilia A - Factor VIIIHemophilia B - Factor IXVon Willebrand DiseaseOther 8. Patient's Dosing Instructions * Please indicate the number of units and recommended frequency of infusion. 9. Preferred Product * Please indicate the product or products the patient is using or would be able to use.