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Project SHARE Factor Donation Form
Complete this form before shipping any donated factor to Save One Life. Incomplete information could result in your donation not being accepted.
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Email
*
Your email
Name
*
Your answer
Type of Clotting Factor Being Donated
*
Hemophilia A
Hemophilia B
von Willibrand Disease
Other:
Factor Brand
*
Your answer
Number of vials being donated
*
Your answer
Lot Number(s) Please separate different lot numbers with commas
*
Your answer
Factor Expiration Date(s) If more than one please separate with commas
*
Your answer
Complete the section below based on whether you are an individual, specialty pharmacy, home care company, treatment center or hemophilia nonprofit organization.
Reason for Donation (Individual)
I've switched products and can no longer use this medication
My dosage has changed and I can no longer use this medication
I am donating for a family member that has passed away
I have excess factor that I cannot use before the expiration date
I have developed an inhibitor or have some other medical reason and no longer respond to my current product.
Other:
Clear selection
Reason for Donation (Non-Profit)
Patient donated to us to donate
Left over from summer camp donations
Specialty pharmacy donated to us
Other:
Clear selection
Reason for Donation (Treatment Center)
Patient donated to us to donate
Patient passed away or moved; did not collect their latest prescription
Short-dated; cannot sell from inventory
Left over from summer camp donation
Other:
Clear selection
Reason for Donation (Pharmaceutical/Specialty Pharmacy)
Patient donated to us to donate
Patient passed away or moved; did not collect their latest prescription
Short-dated; unable to sell
Wrong assay size ordered
Assay size overstocked; unable to sell
Patient switched brands
Brand undesirable; not able to sell
Business closing down
Other:
Clear selection
Thank you for donating your factor. Once you receive a confirmation email, please send the factor to the address below. Email
share@saveonelife.net
if you have any questions. No ice packs are needed in the shipment.
Save One Life, Inc.
Project SHARE
55 Ferncroft Rd
Suite 200
Danvers, MA 01923
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