I hereby grant permission to US THROMBOTIC MICROANGIOPATHY ALLIANCE (the "SPONSOR") to perform certain screening tests as set forth below at my direction, which may include obtaining specimens of blood by venipuncture or finger stick. I authorize the SPONSOR to obtain these screening results, via a certified clinical laboratory and email them to me at the above email address. I understand this will be done at no charge to me. The Sponsor will not submit the tests to any insurance company for reimbursement.  If testing returns critical values which may indicate a serious medical condition, the Sponsor will make reasonable attempts to notify me promptly, including by telephone and by leaving voicemail. I give permission to contact the physician contact listed above to report the critical values.

Deidentified results may be looked at for potential future research

 I HEREBY CERTIFY THAT I HAVE READ THE ABOVE ACKNOWLEDGEMENT AND HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENTS. BY AGREEING BELOW, I CONSENT TO UNDERGO THE LABORATORY TESTING UNDER THE CONDITIONS SET FORTH HEREIN.