Intended for US audiences only

Questions? Call 1-855-250-5111.

For Healthcare Professionals
View Multifocal Motor Neuropathy (MMN) Resources

About MyIgSource
Living With PI
- PI Facts
- Traveling with PI
Shire Treatments
Ask An Advocate
Enroll Now
Social
Facebook
YouTube

Enroll in MyIgSource

Complete the form below to start taking advantage of the many services, resources, and tools available through MyIgSource or call 855-250-5111.

*indicates required field

Patient Legal Guardian Healthcare
Professional Other

Healthcare Professional Type *

Physician Nurse Practitioner/ Physician Assistant Nurse Other Pharmacist

How did you hear about the program? *

First Name *

Last Name *

Email Address *

Confirm Email Address *

Address 1 *

Address 2

City *

State * ZIP Code *

Phone Number *

Area of Focus?

Patient First Name *

Patient Last Name *

Patient Date of Birth *

What health condition are you diagnosed with? *

Are you currently on immunoglobulin (IgG) treatment? *

Yes No

Which IG product are you currently using? *

What is the route of administration? *

Where does the infusion take place? *

What Ig product were you using prior to HYQVIA [Immune Globulin Infusion 10% (Human) with Recombinant Human Hyaluronidase]?*

What was your previous route of administration prior to HYQVIA? *

Where did your infusion take place prior to HYQVIA? *

What speciality pharmacy services do you use? *

How long have you been on IgG treatment? *

What health condition is the patient diagnosed with? *

Is the patient currently on immunoglobulin (IgG) treatment? *

Yes No

Which IG product is the patient currently using? *

What is the route of administration? *

Where does the infusion take place? *

What Ig product were you using prior to HYQVIA [Immune Globulin Infusion 10% (Human) with Recombinant Human Hyaluronidase]?*

What specialty pharmacy do you use? *

How long has the patient been on IgG treatment? *

YES, I would like to receive more information about Shire programs, products and services. By checking this box, I agree to the policy statement below.

I understand that the information I have provided will be used by Shire and its contracted third parties to contact me by mail, email, and phone with helpful information on Shire Immunoglobulin (Ig) treatments and indicated conditions, as well as products and services. Shire will not sell or transfer my name or contact information to any third party for their marketing use. The privacy policy in its entirety can be accessed here.

I understand that Shire collects the information because it is necessary to enable individuals to register for, customize and personalize certain aspects of Shire's programs, resources and communications. Shire uses the information to provide communications on its products and services including valuable resources and tools. Shire may also evaluate the use of these resources and communications with non-identifiable or aggregate information to better address patient needs in the future.

Personal information about you will be accessible to Shire and its subsidiaries, and to individuals and organizations that use personal information solely for and at the direction of Shire. Uses and disclosures of personal information by external individuals and organizations acting on Shire's behalf are governed by agreements that require personal information to be protected appropriately.

I understand that Consent to Participate is voluntary. However, I understand that if I do not consent to participate, I cannot participate in the MyIgSource Program. I may cancel by calling 1-800-423-2090 or writing to Shire Connect, 1200 Lakeside Drive, Bannockburn, IL 60015. Once Shire receives and processes my cancellation request, Shire will not use my personal information going forward. I understand that cancelling my Consent to Participate will not affect any use of my information that occurred before my cancellation request was processes. Unless earlier terminated, this Consent will be valid for so long as I participate in the MyIgSource Program.

I understand that the information I have provided will be used by Shire and its contracted third parties to contact me by mail, email, and phone with helpful information on Shire Immunoglobulin (Ig) treatments and indicated conditions, as well as products and services. Shire may also review de-identified information with my or my child's physician in order to provide feedback regarding this program. Shire will not sell or transfer my name or contact information to any third party for their marketing use. The privacy policy in its entirety can be accessed here.

I understand that Shire collects the information because it is necessary to enable individuals to register for, customize and personalize certain aspects of Shire's programs, resources and communications. Shire uses the information to provide communications on its products and services including valuable resources and tools. Shire may also evaluate the use of these resources and communications with non-identifiable or aggregate information to better address patient needs in the future.

Personal information about you will be accessible to Shire and its subsidiaries, and to individuals and organizations that use personal information solely for and at the direction of Shire. Uses and disclosures of personal information by external individuals and organizations acting on Shire's behalf are governed by agreements that require personal information to be protected appropriately. If you ever decide that you do not want to receive information from us regarding our programs and services, contact us at Shire Customer Service, Shire plc, 1200 Lakeside Drive, Bannockburn, IL 60015 or at 1-800-423-2090.

Child Privacy

This site does not seek to collect personal information from children under the age of 13 and will not retain this information if aware of its receipt.

For more information, see our Privacy Statement.

This information is intended only for residents of the United States.

Please fill out all required fields and resubmit

Terms and Conditions
Privacy Policy
Contact Us
About Shire
Sitemap

© 2018 Shire US Inc., Lexington, MA 02421. All rights reserved. 1-800-828-2088.

SHIRE and the Shire Logo are registered trademarks of Shire Pharmaceutical Holdings Ireland Limited or its affiliates. CUVITRU, GAMMAGARD LIQUID, GAMMAGARD S/D, HYQVIA, IGI, MyIgSource and We've Got You Covered are trademarks or registered trademarks of Baxalta Incorporated, a wholly owned, indirect subsidiary of Shire plc.

All other product brands or trademarks appearing herein are the property of their respective owners.

S41675 09/18

Shire