PATS Hepatitis Foundation International
504 Blick Drive
Silver Spring, MD 20904-2901
301-622 4200

Patient Advocacy Telephone Support network (PATS) Registration Form.

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Please print out this form, fill it out, sign and mail it to above address.

( ) Yes, I would like to participate in HFI's PATS network.

( ) I give HFI permission to share my phone number with others in my area who have the following:   
   HAV  HBV  HCV  Cirrhosis  (circle any that apply)

(Please print legibly):

First name: ____________________________________

Last name: ____________________________________

Street Address:__________________________________

City: ________________________ State: ______ ZIP: ____________

E-mail address: ______________________________________

Phone number with area code:  (_______)______________________

Full signature required for participation: ______________________________

My contribution of $_______________ is enclosed.

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When complete, please mail this form to the address above

Thank you!