IGA Humanitarian Aid Support form

IGA Humanitarian Aid Support form

Please fill the form in as completely as possible and upload the required documents. Omissions could delay any help we may be able to arrange.
Approval status
Date of submission

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Details of person completing this form on behalf of the patient (Parent or Referring Adult)

If you are submitting this form on your own behalf, please skip to Patient details below.
Name

First NameLast Name
Telephone number including country dialling code

Country CodeArea CodePhone Number
Email
example@example.com
Country
Relationship to patient
If the patient is 16 years of age or under
Is the child under 2?
Has the child ever received ERT?
If yes, why was it stopped?
Please upload proof of your parenthood/guardianship.

Cancelof
Signature
Patient's details
Patient's Name

First NameLast Name
Guacher type
Patient's postal address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's country
Email
example@example.com
Patient's telephone number including country dialling code

Country CodeArea CodePhone Number
Patient's gender
Patient's birthdate

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Please upload proof of Gaucher diagnosis. This can be anything that confirms that the patient has Gaucher disease, including genetic results, enzyme results, a physician's letter/email that names the patient and confirms diagnosis/treatment.

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BY COMPLETING THIS FORM YOU ARE GIVING THE IGA PERMISSION TO SHARE THE INFORMATION CONTAINED WITH OTHER PARTIES AND STAKEHOLDERS WHO MAY BE ABLE TO HELP WITH YOUR SITUATION

Privacy Statement:

Your details are safe with us. We will always store your personal details securely. We will only use them to provide the service(s) that you have requested and communicate with you in the way(s) you have agreed to. Your details may also be used for analysis purposes, to help us provide the best possible service. We will not pass on your details to anyone else except as detailed above and we will only share them if required to do so by law.
The International Gaucher Alliance (IGA) may store the information I have provided on this form, share it with selected third parties for the purpose of obtaining charitable access to treatment, and communicate with me about my request.
Physician's details
Physician's name

First NameLast Name
Full postal address of physician's hospital/practice

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's country
Physician's phone number

Country CodeArea CodePhone Number
Physician's email address
example@example.com
Please verify that you are human
Responded to patient on

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Pharma contacted on

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Pharma company
Treatment approved
If yes, date of email confirming treatment

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Email confirming treatment approval

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If no, reasons given
Patient is deceased
Date of death, if known

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Notes
Should be Empty:

IGA Humanitarian Aid Support form

Details of person completing this form on behalf of the patient (Parent or Referring Adult)

Patient's details

Physician's details