Seatbelt Strap Form

Please fill out the form below if you have received a seatbelt strap or would like one mailed to you.

This program is only open to people living with bleeding disorders in North Carolina or those who live outside of North Carolina but are patients of a North Carolina Hemophilia Treatment Center.
Maximum of 2 seat belt straps available per patient diagnosed with a bleeding disorder. Please fill out a separate form for each patient in the household.