An asterisk(*) identifies each required field. I am*: New to IDF   Updating existing information I am*:  (check all that apply) Physician Nurse Other:  Contact Information: First Name*: Last Name*: Degree: Other Degrees: Address 1*: Address 2: City*: State*: Zip Code*: Country*: Employer: Job Title: Name of Practice: Size of Practice: Website: Hospital Affiliation: Telephone: E-mail*: Please indicate your specialty (select any that apply)*: Allergy Immunology Chest Medicine Infectious Disease ENT Internal Medicine Family Practice Pediatrics Hematology Rheumatology None of These or Other: Do you follow any patients with a Primary Immunodeficiency Disease (PIDD)?* Yes No How many patients do you follow that have a PIDD?* (Enter 0 if you have not yet treated a patient with a PIDD)   patients Do you treat or manage patients with immunoglobulin therapy?* Yes No Please tell us about the PIDD patients you follow: Do you follow any patient with any of the following diagnoses? (check all that apply) Please indicate whether the patients with the corresponding diagnosis are adults or children. (check all that apply) Agammaglobulinemia (XLA) Adult Pediatric Ataxia Telangiectasia Adult Pediatric Chronic Granulomatous Disease Adult Pediatric Common Variable Immunodeficiency Adult Pediatric Complement Deficiency Adult Pediatric DiGeorge Syndrome Adult Pediatric Hereditary Angiodema Adult Pediatric Hyper IgM Syndrome Adult Pediatric IgG Subclass Deficiency Adult Pediatric Severe Combined Immunodeficiency Adult Pediatric Severe Congenital Neutropenia Adult Pediatric Specific Antibody Deficiency Adult Pediatric Wiskott-Aldrich Syndrome Adult Pediatric Other: Adult Pediatric Please list all professional memberships: Please list all Board Certifications:   Captcha Code:      Can't read the code? Click the image for a new one. Re-type Captcha Code*:

If you currently manage patients with a Primary Immunodeficiency Disease, IDF encourages you to please take a moment to read about the United States Immunodeficiency Network (USIDNET)
Working under a grant from The National Institutes of Health and National Institute of Allergy and Infectious Diseases (NIH/NIAID), the United States Immunodeficiency Network (USIDNET) is developing a national registry of patients with primary immunodeficiency diseases for the purposes of:

• Providing a minimum estimate of the prevalence of each disorder in the United States
• Promoting collaborative research
• Learning more about phenotypic variations
• Determining the natural history of these genetic disorders
• Providing a comprehensive clinical picture of each disorder
• Learning the effects of treatment protocols
• Evaluating quality of life measures in this patient population
• Providing a resource for clinical and laboratory research

If you would like to learn more about the Registry, please visit www.usidnet.org.