Secondary Immune Deficiencies Membership

As IDFA has just begun to assist this new membership group, we will be developing new resources. As patients with Secondary Immune Deficiencies have similar issues to those with Primary Immune Deficiencies we will still send you a membership resource pack with information on Common Variable Immune Deficiency (CVID), which is similar to hypogammaglobulinaemia, immunoglobulin replacement therapy, autoimmune disease, fatigue, staying healthy, school and transition.

Type of membership:

Parent to complete if patient under 18 years of age


Patient Name: *
Parent Name 1:
Parent Name 2:
Spouse/Partner Name:
Sibling 1 Name (if relevant):
Sibling 2 Name (if relevant):
Sibling 3 Name (if relevant):
Address (needed to post resource packs):
Phone:
-
Mobile Number:
Don't call:
E-mail: *
Are you of Aboriginal / Torres Strait Islander descent?:
Nationality:
Is English your primary language?
If "no", what is your primary language?
Patient gender:
Patient date of birth:
 /  / 
Patient Age
The patient is:
Patient age at diagnosis
Who first suspected the diagnosis? *
Immune Deficiency: *
If "other", list:
Immune Deficiency secondary to chemotherapy for: *
If "other" list:
Immune deficiency secondary to Autoimmune Disease: *
If other please list: *
Treating Physician: *
Treatment:
Other treatment (list):
Main hospital for treatment:
Other treatment / medications:
Other Specialists involved in the Patient's care:
Other significant illnesses:
About me (Tell us about you):
I wish to receive IDFA information (newsletters, patient meetings, conferences, research) by:
Patient/Parent - Please check the relevant fields - currently IDFA resources apply to primary immune deficiencies but we will send you "cross over" resources that we hope are applicable until we have developed ID resources:
Statistics and research:
Advocacy submission:
How did you hear about IDFA?:
Patient linking:
I give my permission for my email address to be used for patient linking:
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