» IDFA Membership Patients, Carers & Families Immune Deficiencies Foundation Australia

Type of membership:

Parent to complete if patient under 18 years of age

Patient Name:


First	Last

Parent Name 1:


First	Last

Parent Name 2:


First	Last

Spouse/Partner Name:


First	Last

Sibling 1 Name (if relevant):


First	Last

Sibling 2 Name (if relevant):


First	Last

Sibling 3 Name (if relevant):


First	Last

Healthcare Professional Name:


First	Last

For Healthcare professional members, list field:

Immunologist

GP

Paediatrician

Researcher

Nurse

CNC

Respiratory Physician

Gastroenterologist

Rheumatologist

Neurologist

Psychologist

Allergist

Oncologist

Other (list)

Stakeholder Name:


First	Last

Stakeholder Company:

Address (needed to post resource packs): *

Street AddressStreet Address Line 2CityState / Province / RegionPostal / Zip CodeCountry

Phone:

-
Area Code	Phone Number

Mobile Number:

Don't call:

I do not I do not wish to leave my phone number

E-mail: *

NOTE:

Are you of Aboriginal / Torres Strait Islander descent?:

Yes

No

Nationality:

Is English your primary language?

Yes

No

If "no", what is your primary language?

Patient gender:

Male

Female

Patient date of birth:

	/		/
day		month		year

Patient Age

The patient is:

Patient age at diagnosis

Who first suspected the diagnosis of PID? *

Confirmed PID: *

If "other", list name of PID:

Immunologist (or treating clinician) Name:(1) *

Treatment:

Other treatment (list):

Main hospital for treatment:

Medications:

Other Specialists involved in the Patient's care:

Co-morbidities (other illnesses):

Bronchiectasis

Lung disease

Chest Infections

Asthma

Sinus infections

Bowel disease

Endocrine disorder

Osteoarthritis

Rhuematoid Arthritis

Neurological Disorder

Skin issues

Allergies

Fatigue

Depression

Anxiety

Autism

Aspergers

Cancer

Other (list)

Other significant illnesses:

Cancer (select):

CLL (Chronic Lymphocytic Leukaemia)

Hodkins Lymphoma

Multiple Myeloma

Lymphoreticular Malignancy

Other (list)

Other Cancer (list):

Patient/Parent - Please check the relevant fields:

I wish to receive IDFA information about my specific PID

I would like to join the IDFA closed Facebook Group

I would like to join YAMS - IDFA's youth and young adult members

I would like to IDFA to contact me

I am interested in participating in PID Chat - teleconferences with members of a similar age with the same PID

I would like to attend a patient meeting in my State

I am interested in attending a National Conference

I am interested in any media requests to support IDFA

I would like to Volunteer for IDFA as part of the Speakers Network (speaking at Rotary, Lions, events, schools etc)

I would like to Volunteer for IDFA as a Fundraiser

I would like some IDFA brochures to leave at my local doctor, hospital, immunologist’s rooms

About me (Tell us about you):

I wish to receive IDFA information (newsletters, patient meetings, conferences, research) by:

email

mail

Statistics and research:

I give permission for IDFA to release my name or my child's name (if under 18) and details to IDFA Support Staff and the IDFA Medical Panel in order to enable full participation and support by the Foundation

I give permission for IDFA to use my details or my child's details (if under 18) for advocacy, research and fundraising submissions. E.g. Country of origin, Gender, Age, Type of PID, Age at diagnosis, Treatment, Hospital and Other significant illnesses. IDFA will not use personal details such as name, address or contact information.

I am interested in participating in clinical trials

Advocacy submission:

I support IDFA making a submission for the introduction of Newborn Screening of infants for Primary Immune Deficiencies (PID) in Australia, to allow for early interventions

If "other", list:

How did you hear about IDFA?:

Patient linking:

I would like to be in touch with someone with the same PID

I would like to be put in touch with someone of a similar age

I would like to be put in touch with someone with PID in the same State

I give my permission for my email address to be used for patient linking:

Yes

No

Word Verification: