Patient Contact Information

I am:  (check all that apply)

 Patient with a Primary Immunodeficiency Disease  Parent/Caregiver*
 Other: 

*Parents - Please update your information. If your child is an adult patient and no longer resides with you, please either fill out your child's information or forward to your child for completion.
 
Patient Parent/Caregiver/Other
   


This section for patients and parents/caregivers

What is the patient's current diagnosis?

  Agammaglobulinemia (XLA)   IgG Subclass/SpecificAntibody Deficiency
  Ataxia Telangiectasia   Selective IgA Deficiency
  Chronic Granulomatous Disease   Severe Combined Immunodeficiency
  Common Variable Immunodeficiency   Wiskott-Aldrich Syndrome
  Complement Deficiency   Not sure
  DiGeorge Syndrome   Other:  
  Hyper IgM Syndrome

What primary health insurance does the patient currently have? (Select one)

Employer coverage Other group coverage
Individual policy Medicare
Medicaid Other

What treatment does the patient receive? (Select one)

Intraenous Immunoglobulin (IVIG)*
Subcutaneous Immunoglobulin (SCIG)*
Neither

*What is the current brand of IVIG or SCIG used?

  
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