Every Voice Counts

Take a few moments and get connected

By completing this form, you are playing a vital role in maintaining the largest database of individuals whose lives are affected by primary immunodeficiency diseases. Your information enables IDF to perform valuable surveys that have been, and will continue to be instrumental in advancing the needs of the primary immunodeficiency community. Your name and contact information will not be shared with other organizations and this information will be kept strictly confidential.

Being a part of IDF has wonderful benefits for you! We will keep you informed of the latest news regarding treatment, education, recalls, programs and other timely issues for those living with primary immunodeficiencies, via the Primary Immune Tribune monthly e-newsletter, and the IDF ADVOCATE printed newsletter.

So what are you waiting for? Please take a few moments and fill in the following information.

I am: New to IDF  Updating existing information I am:  (check all that apply) Patient with a Primary Immunodeficiency Disease  Parent/Caregiver* Other:  *Parents - please complete the form below. If your child no longer resides with you, please either fill out your child's information or forward the information for this webpage to your child.   Patient Parent/Caregiver/Other First Name: First Name: Last Name: Last Name: Address 1: Address 1: Address 2: Address 2: City: City: State: State: Zip Code: Zip Code: Country: Country: Telephone: Telephone: E-mail: E-mail: Date of Birth:     At what age was the patient diagnosed as having a Primary Immunodeficiency?   What is the patient's current diagnosis?   Agammaglobulinemia (XLA)   Selective IgA Deficiency   Ataxia Telangiectasia   Severe Combined Immunodeficiency   Chronic Granulomatous Disease   Wiskott-Aldrich Syndrome   Common Variable Immunodeficiency   Not sure   Complement Deficiency   Other:     DiGeorge Syndrome     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) Intravenous Immunoglobulin (IVIG)* Subcutaneous Immunoglobulin (SCIG)* Neither *What is the current brand of IVIG or SCIG used? Enter brand name here:   -- SELECT BRAND NAME -- Carimune (CSL Behring) Flebogamma (Grifols) Gammagard S/D (Baxter) Gammagard Liquid (Baxter) Gamunex (Talecris) Octagam (Octapharma) Privigen (CSL Behring) Vivaglobin (CSL Behring) Other Periodically, IDF conducts focus groups; would you be interested in participating? Yes No For security purposes, please enter the special code: Thank you for your time and commitment to IDF!