IVIG Indications Form
Use this form to evaluate and document whether IVIG is being considered. Please complete all relevant sections.
Patient Initials
*
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Primary Diagnosis
*
Indication for IVIG
*
Please Select
Primary Immunodeficiency
Secondary Immunodeficiency
Autoimmune/Neurological Disorder
Other
Has the patient received prior IVIG therapy?
*
Yes
No
If yes, provide details on previous IVIG therapy (dose, frequency, response)
Other therapies attempted prior to IVIG
Urgency of IVIG initiation
*
Please Select
Routine
Urgent (within 7 days)
Emergent (within 24 hours)
Referring Provider Name
*
Additional Comments or Clinical Rationale
Submit
Should be Empty: