IVIg Infusions
CURRENT PRIOR AUTHORIZATION
EXPIRES 25 JUNE 2016

IVIg Rx
Current Prescription Expires
25 April 2016

200g Gammagard
Liquid 10%
(2000 ml) Monthly

40g (400ml)/day over 5 days
Pharmacy

Crescent Healthcare

11980 Telegraph Rd.
Suite 102
Santa Fe Springs, CA 90670
877-872-4844
NOTE:
To date, have experienced
NO ADVERSE SIDE EFFECTS
from IVIg Therapy

Current Weight: 220 lbs. (99.79 kg)
BARD PowerPort implanted
23 June 2011