Human Normal Immunoglobulin (10%)

Recombinant Human Hyaluronidase

RESOURCE BINDER

C-APROM/CA/HYQ/0005
 Human Normal Immunoglobulin (10%)
Recombinant Human Hyaluronidase

TRAINING

C-APROM/CA/HYQ/0007
Human Normal Immunoglobulin (10%)
Recombinant Human Hyaluronidase
You have been prescribed
HyQvia by your doctor.
Visit hyqvia.ca to find out more about:
• How HyQvia is given
• How to self-infuse HyQvia
• Possible side effects
• OnePath® Patient Support Program

You can log on to the HyQvia website using the

HyQvia drug identification number (DIN): 2524406

HYQVIA® is a registered trademark of Baxalta Incorporated.

ONEPATH® is a registered trademark of Takeda.
Copyright © 2023 Takeda Pharmaceutical Company Limited. All rights reserved. TAKEDA® and the
TAKEDA Logo® are trademarks of Takeda Pharmaceutical Company Limited, used under license.
PRMCDA/CA/HYQ/0012 October 2023
RESOURCES &
PATIENT ASSOCIATIONS

Resources

HyQvia
hyqvia.ca

Takeda Canada
takeda.com/en-ca

OnePath
onepath.ca

Patient Associations

ImmUnity Canada
immunitycanada.org

NORD
rarediseases.org

Immunodeficiency Canada
immunodeficiency.ca

C-APROM/CA/HYQ/0009
 Human Normal Immunoglobulin (10%)
Recombinant Human Hyaluronidase

HYQVIA® is a registered trademark of Baxalta Incorporated. Copyright © 2023 Takeda Pharmaceutical Company Limited. All rights reserved.
TAKEDA® and the TAKEDA Logo® are trademarks of Takeda Pharmaceutical Company Limited, used under license. C-APROM/CA/HYQ/0010
 Human Normal Immunoglobulin (10%)
Recombinant Human Hyaluronidase

INFUSION LOG

C-APROM/CA/HYQ/0007
 Phone: 1-844-MY-1PATH Infusion therapy:
Fax: 1-844-951-PATH
Email: support@onepathprogram.ca
Hours: 8 am to 8 pm EST M-F
[Immunoglobulin Subcutaneous (Human) 20%]

Name: Date of birth: DD/MMM/YYYY Infused From: DD/MMM/YYYY To: DD/MMM/YYYY

Completed Infusions
Duration # of Reaction? Yes/No Medications
Infusion site (If yes, please ensure any reactions are
Date of infusion Lot number and expiry date of infusion infusion taken before/
description reported as adverse events to Takeda
(min) sites within 1 business day) during

DD/MMM/YYYY

DD/MMM/YYYY

DD/MMM/YYYY

DD/MMM/YYYY

DD/MMM/YYYY

Wastage log If wasted, indicate whether Date # of vials

Date product Lot number and expiry date Notes
picked up
returned to Transfusion Service wasted wasted

ONEPATH® is a registered trademark of Takeda Pharmaceutical Company Limited.

HYQVIA® is a registered trademark of Baxalta Incorporated.
CUVITRU® is a registered trademark of Baxalta Incorporated.
Copyright © 2024 Takeda Pharmaceutical Company Limited. All rights reserved. TAKEDA® and are registered trademarks of Takeda Pharmaceutical Company Limited, used under license.

C-APROM/CA/CUVI/0001
 Human Normal Immunoglobulin (10%)
Recombinant Human Hyaluronidase

ORDERING
SUPPLIES

C-APROM/CA/HYQ/0007
 HYQVIA® SUPPLIES
ORDER FORM
Patient Name/ID:
INFUSION SUPPLIES Date:
Ship to Name:
Preferred delivery date:
Please carefully review the list below and indicate which Ship to Address:
ancillary devices you would like to order and the quantity
of each that you require. Preferred phone number:

Product ID Product Description Quantity Quantity

Per Box Required
Start of Infusion
CS001148 Webcol Alcohol Prep Pads 200
CS002011 Blunt Needle (18G, 1 1/2”) 100
CS003012R Syringe 10ml Luer-Lok 200
CS003003 Syringe 20ml Luer-Lok 48
CS003009 Syringe 30ml Luer-Lok 56
CS004090 AP409 Sapphire Pump Infusion Set 30
CS006225 IV Pole 1
Single Lines
CS002479 OPTFlow SUB-Q 1 Needle Set, 26G x 9mm 50
CS002480 OPTFlow SUB-Q 1 Needle Set, 26G x 12mm 50
CS002481 OPTFlow SUB-Q 1 Needle Set 26G x 14mm 50
CS002068 SAF-Q Soft-Glide 1 Needle Set, 24G x 9mm 50
CS002069 SAF-Q Soft-Glide 1 Needle Set, 24G x 12mm 50
CS002486 High-Flo SubQ 1 Needle Set, 24G x 14mm 20
Double Lines
CS002483 OPTFlow SUB-Q 2 Needle Set, 26G x 9mm 10
CS002484 OPTFlow SUB-Q 2 Needle Set, 26G x 12mm 10
CS002465 OPTFlow SUB-Q 2 Needle Set 26G x 14mm 10
CS002070 SAF-Q Soft-Glide 2 Needle Set, 24G x 9mm 10
CS002071 SAF-Q Soft-Glide 2 Needle Set, 24G x 12mm 10
CS002487 High-Flo SubQ 2 Needle Set, 24G x 14mm 20
End of Infusion
CS001120 Flush: 0.9% NaCl FK 50ml Luer Lock 60
CS001053R Gauze 2" x 2" 4 ply 50
CS001226 Sharps Container 1
CS001023 Tape Micropore 1" x 10yd 12
CS001004R Bandaids 100
CS001097 IV 3000 Transparent Film 6x7cm 100
CS001055 Tegaderm Film 6x7cm 100

Please scan or photograph your completed form and send it to the OnePath Program at support@onepathprogram.ca.
If you have any questions, you can reach a OnePath Care Manager via phone: 1-844-691-7284
or email: support@onepathprogram.ca.

HYQVIA® is a registered trademark of Baxalta Incorporated.

Copyright © 2023 Takeda Pharmaceutical Company Limited. All rights reserved. TAKEDA® and the
TAKEDA Logo® are trademarks of Takeda Pharmaceutical Company Limited, used under license.
Human Normal Immunoglobulin (10%)
C-APROM/CA/HYQ/0012 October 2023 Recombinant Human Hyaluronidase
 Human Normal Immunoglobulin (10%)
Recombinant Human Hyaluronidase

SAFETY
INFORMATION

JOB NUMBER
C-APROM/CA/HYQ/0007
Infusing HyQvia® treatment directly
from vials with a peristaltic infusion pump
A step-by-step guide for patients and caregivers
Additional information following training from your healthcare team

HyQvia is used to treat adult patients with primary immunodeficiency diseases

(PI) and with secondary immunodeficiency diseases (SI).

This guide is intended for use after a patient has been prescribed HyQvia.

This material was developed by Takeda as part of the risk minimization

plan for HyQvia. This material is not intended for promotional use.

© 2023 Takeda Pharmaceutical Company Limited. All rights reserved.

 Introduction

Infusion overview

You have received this step-by-step guide because your

healthcare professional has prescribed HyQvia treatment for you
or the person you are caring for. This guide is designed to help
you infuse HyQvia using a peristaltic infusion pump. Use this
guide for the direct-from-vial method. If you have any questions or
concerns about how to infuse HyQvia, please discuss them with
your healthcare professional.

Infuse HyQvia only after you have been trained by your

healthcare professional and have read the information in the HY
Package Leaflet.

IG
Healthcare professional name and phone number:

HY = recombinant human hyaluronidase

xxxx IG = human normal immunoglobulin (IG 10%)

2
The 5 steps to infusing HyQvia treatment

Get ready Prepare the HY Prepare the IG Infuse HyQvia Finish up

• Inspect vials • Draw HY into syringe(s) • Draw IG into • Insert and secure needle • Remove needle
pump tubing
• Gather supplies • Attach to needle set • Infuse HY • Log infusion
manually (first)
• Wash hands • Fill needle set
• Infuse IG
with pump (second)

Infuse HyQvia only after you have been trained by your healthcare professional and have read the information in the HyQvia package leaflet.

3
 What you’ll need

Below are the supplies you’ll need to infuse HyQvia treatment. Your supplies may look slightly different.

HyQvia vial(s) Alcohol swabs, tape and clean, 20 mL syringe(s)† Optional: sterile tip caps
sterile bandage* (one per syringe)

Non-vented device or needle Subcutaneous needle set with a sterile Vented pump tubing Peristaltic infusion pump, power supply
(one per HY vial) dressing (one per infusion site) and manual

Optional: saline infusion bag (if required Sharps container Log book
by your healthcare professional)

*Wear gloves if instructed by your healthcare professional.

†
These are the recommended syringe volumes.

4
How they fit together

A B C

HyQvia vial(s)
20 mL syringe(s)
HyQvia vial(s)

Optional: saline
infusion bag

Non-vented
device or needle

Vented pump tubing

Subcutaneous
needle set

20 mL syringe(s)
Peristaltic infusion pump

Transfer the HY into the syringe(s) Infuse the HY manually (first) Infuse the IG using the peristaltic pump (second)

5
 STEP 1

Get ready

6
 A B C D

Remove HyQvia from the box and Gather your supplies. Clean your work area. Wash your hands thoroughly.
inspect it. Check the colour and expiry
date. Make sure the liquid isn’t cloudy
and doesn’t have particles in it. Allow
HyQvia to reach room temperature (this
may take up to 60 minutes). Do not use
heating devices including microwaves.
Do not shake HyQvia.

Open supplies as instructed by your

healthcare professional.

7
 STEP 2

Prepare the HY

8
 A B C D
Syringe for HY

Remove the cap. Clean each vial of HY Remove the 20 mL sterile syringe from Pull back on the plunger to fill the Insert the non-vented device or needle
by wiping the stopper with an alcohol its package.* Attach a non-vented syringe with air (an amount equal to the into the centre of the HY vial stopper.
swab and allowing to dry for at least device or needle to the syringe. full amount of HY). Push the air into the vial.
30 seconds. Prepare a label for the HY
syringe and set it aside.

E F G
TIP
Cover each syringe with a
sterile tip cap when drawing
up multiple syringes.

Turn the vial upside down. Pull back on When the full dose has been transferred Attach the subcutaneous needle set to
the plunger to withdraw all of the HY into the syringe, hold the syringe the HY syringe. Slowly push the plunger
into the syringe. Repeat steps C to E if upright and gently tap it to remove air to fill the needle set tubing to the needle
more than one vial of HY is needed for bubbles. Then slowly push the plunger wings. Close the clamp on the needle
your dose. Use the same syringe, if until the HY reaches the tip of the set tubing. Label the syringe HY.
possible. barrel.

*This is the recommended syringe volume.

9
 STEP 3

Prepare the IG

10
 A B C D

Clean each vial of IG by wiping the Close the clamp on the vented pump Insert the spike of the vented pump Fill the vented pump tubing with IG, as
stopper with an alcohol swab and allow tubing. tubing straight down into the IG vial instructed by your healthcare professional.
to dry for at least 30 seconds. stopper. Turn the vial upside down and
hang it from an intravenous pole or
hook.

Following the manufacturer’s

instructions, programme the pump for
the prescribed infusion flow rates. Turn
off the pump.

11
 STEP 4

Infuse HyQvia
Remember: HY before IG

12
 A B C D

Choose an infusion site (or sites) in either Remove the subcutaneous needle If more than one infusion site is used, Slowly push the plunger of the smaller
the abdomen or thigh. Avoid bony areas, cover. Pinch at least 2.0 to 2.5 cm repeat steps A through C. Open the syringe with the recombinant HY at
visible blood vessels, scars and any of your skin. Insert the needle with a clamp on the needle set. Check for an initial rate of 1 to 2 mL per minute
areas of inflammation or infection. Rotate rapid motion straight into the skin at a proper needle placement before starting and increase as tolerated. If more than
your infusion sites to opposite sides of 90-degree angle. Open the needle set the infusion, as instructed by your one site is used, divide the HY equally
the body between infusions.* Clean the wings and secure the needle in place healthcare professional. between sites.
infusion site(s) with an alcohol swab, as with a sterile dressing.
instructed by your healthcare professional.
Allow to dry for at least 30 seconds.

E F G

90˚

When all of the HY has been infused, Open the clamp on the vented pump When the vial is empty, pause the pump
remove the syringe and attach the same tubing and start the pump to infuse and reprogramme if needed. Insert the
subcutaneous needle set to the vented the IG at the rate prescribed by your spike of the vented pump tubing into
pump tubing. Do not remove the needle healthcare professional. The IG infusion the next cleansed IG vial. Then restart
from your infusion site(s). should be started within 10 minutes the pump. Repeat for each remaining
after completing the HY infusion. IG vial.

*For patients with a body weight of <40kg, select sites on opposite sides of body if instructed to infuse in 2 sites for doses above 300 mL.
For patients with a body weight of >40kg, select sites on opposite sides of body if instructed to infuse in 2 sites for doses above 600 mL.
13
 STEP 5

Finish up

14
 A B C D

Skin

Subcutaneous layer
Muscle layer

If instructed to do so by your healthcare Restart the pump to flush the IG up to Turn off the pump and close the clamp Remove the subcutaneous needle set
professional, when the last IG vial is the needle wings. on the vented pump tubing. Remove the by loosening the sterile dressing on all
empty, remove it and attach the saline tubing from the pump. edges. Pull the needle wings straight up
infusion bag to the vented pump tubing. and out. Gently place the clean, sterile
bandage over the infusion site.

E F G

Dispose of the needle set in the sharps Record the infusion details in your Follow up with your healthcare
container and throw away any unused log book. professional, as directed.
product in the vial and disposable
supplies, as recommended by your
healthcare professional.

15
 What it looks like when you infuse HyQvia treatment

Following your infusion with HyQvia, you may experience swelling at the infusion site. Swelling should only last for a few days.

Before, during and after HyQvia treatment

Example of a patient on HyQvia. Your body may react to your HyQvia infusion in the same way, or differently.

Before HyQvia infusion Right after HyQvia infusion 24 hours after infusion
HyQvia infused: 235 mL (volume infused as per the healthcare professional’s guidance
based on this patient’s specific clinical condition; it may be different for you).

16
What are possible side effects from using HyQvia?

These are not all the possible side effects you may have when taking HyQvia. If you experience any side effects not
listed here, tell your healthcare professional.

After HyQvia infusion a temporary, soft swelling may occur around the infusion site, which may last 1 to 3 days, due to
the volume of fluid infused.

The following local reactions may occur at the site of infusion and generally go away in a few hours:
• Mild or moderate pain, Redness, Swelling, Itching.

Local reactions are less likely after the first few infusions. The most common side effects of HyQvia are:
• Headache, Fatigue, Nausea, and Fever.

Serious warnings and precautions

Immunoglobulin (Human) products have been reported to be associated with heart and blood circulation problems
such as heart attack, stroke and blood clots (thrombosis). Some of these risk factors include obesity, old age,
prolonged periods of immobilization, high blood pressure, diabetes, or a history of heart disease. Thrombosis may
also occur even in the absence of known risk factor.

Talk to your doctor if you have risk factors for these kinds of conditions. Do not use HyQvia at home until you get
instructions and training from your healthcare professional. When using HyQvia at home, you must assign a guardian
person who will help you watch out for allergic reactions, stop the infusion, and get help if necessary.

Tell your healthcare professional immediately if you notice any of these signs during the infusion.

17
 Managing possible side effects of HyQvia treatment

Local side effects

The following local reactions may occur at the site of infusion and usually go away within a few days. Always contact your healthcare
professional to find out how best to manage any local reaction that increases in severity or persists for more than a few days.

Discomfort or pain at the infusion site when inserting the subcutaneous needle
• Talk to your healthcare professional or speciality pharmacy about changing the length of your needle; it may be too long for you. The
thickness of subcutaneous tissue can be different from person to person depending on age, gender, body mass index, and the site of
infusion
• Note in your logbook that this site may not work for you

Discomfort, pain, or redness at the infusion site during or after your infusion
• Please talk to your healthcare professional, who may slow or stop the infusion
• Talk to your healthcare professional about a possible allergy to your tape or dressing or the possible use of a mild pain reliever

Swelling at or around the infusion site

After HyQvia infusion, a temporary swelling can occur due to the volume of fluid infused.

18
Itching or rash at or around the infusion site Other less frequent side effects are listed in the HyQvia Package
• Talk to your healthcare professional about the possible use of an Leaflet including serious but rare allergic reactions. It’s also possible
antihistamine, if recommended that you may experience side effects that are not discussed in the
HyQvia Package Leaflet. Please talk to your healthcare professional if
If you experience itching or rash/hives, stop your infusion you experience any side effects, particularly those that are not listed
immediately and contact your healthcare professional or in the Package Leaflet, are severe, or last longer than a couple of
emergency services; these could be signs of a serious allergic days.
reaction
Please note: the suggestions above should not replace your
Generalised (systemic) side effects healthcare professional’s direction/advice.

Generalised side effects affect the whole body rather than a specific You can also report side effects associated with the use of health
part. The most common generalised side effects include: products to Health Canada by:

Headache • Visiting the Web page on Adverse Reaction Reporting

(https://www.canada.ca/en/health-canada/services/drugs-
• Talk to your healthcare professional about using an over-the- healthproducts/medeffect-canada.html) for information on how
counter pain reliever to report online, by mail or by fax; or
• Contact your healthcare professional if the headache persists or
worsens • Calling toll-free at 1-866-234-2345.

Fever • Or send an email to Takeda at AE.CAN@takeda.com to report

any side effects.
• Talk to your healthcare professional about using an over-the-
counter medicine to reduce the fever Note: Contact your health professional if you need information
• Contact your healthcare professional if the fever persists or about how to manage your side effects. The Canada Vigilance
worsens Program does not provide medical advice.. By reporting side
effects, you can help provide more information on the safety of
this medicine.

19
 Patient and caregiver resources

Helpful PID communities and support organisations

Joining community groups and patient advocacy organisations is another way
you can take control of your primary immunodeficiency (PID). You may find these
organisations helpful.

International Patient Organisation for Primary Immunodeficiencies (IPOPI)

http://www.ipopi.org/

Jeffrey Modell Foundation

http://info4pi.org/

European Society for Immunodeficiencies (ESID)

http://esid.org/

Immunity Canada

https://immunitycanada.org/#what-is-pi#

20
Notes

21
Reference
1. HyQvia Canada Product Monograph, December 2022.

VV-MEDMAT-96063
Scan this QR code or go to
https://axian.link/hyq-pat-can
to access additional safety
information for HyQvia.
 Human Normal Immunoglobulin (10%)
Recombinant Human Hyaluronidase

PATIENT TRAVEL
INFORMATION

JOB NUMBER
C-APROM/CA/HYQ/0007
 Human Normal Immunoglobulin (10%)
Recombinant Human Hyaluronidase

Are you planning to travel abroad?

Dear Patient,

Traveling while receiving treatment for primary or secondary immunodeficiency disease may seem to be a
daunting task. But there is nothing to stop anyone who is receiving Ig replacement therapy from going on a
holiday, especially if you are well-prepared and take appropriate precautions during your trip.

Because HyQvia is infused once every 3-4 weeks, you may not need to take your treatment supplies with you
during travel! For longer trips, this section of your Resources Binder provides information and tips to assist
you with your travel planning. Should you require additional information, your OnePath team is ready to help.
As a first step, please contact your Care Manager to discuss your travel plans and questions. Also, be sure
to discuss your travel plans with all of the doctors/nurses who are managing any other medical condition you
may have, over and above immune deficiencies.

This Travel Planning Information section includes:

• Travel information letter – Highlights key planning steps, what you should discuss with your doctor/
nurse and what documents and supplies you should plan to bring with you.
• Medical supplies travel letter – A medical letter signed by your doctor that explains why you are
travelling with vials of HyQvia and supplies necessary for infusions while away.
• ‘Vaccine exemption’ form for travelers – A medical form for patients whose doctors have advised
against receiving COVID-19 vaccines.

Although most COVID-19 travel restrictions have eased, you should consult local/provincial public health
guidelines for the most current recommendations and updates. The Public Health Agency of Canada currently
advises travelers to practice enhanced health precautions when travelling, as COVID-19 continues to circulate
in Canada and internationally. The virus continues to change over time and new variants will continue to
appear. So, make sure to consult with your healthcare team at least 6 weeks before you travel.

We look forward to assisting you with your journey.

Bon voyage,
OnePath Team

C-APROM/CA/HYQ/0013
Human Normal Immunoglobulin (10%)
Recombinant Human Hyaluronidase

KEY INFORMATION FOR PEOPLE WHO WANT TO

TRAVEL WHILE BEING TREATED WITH HYQVIA
A summary

The information and tips provided in this summary are intended to help you with your travel preparations and
to make them less stressful.

Be sure to discuss your travel plans with all of the doctors/nurses who are managing any other medical
condition you may have, over and above immune deficiencies.

Determine what travel restrictions may still be in place – Although most COVID-19 travel restrictions have
eased, you should consult local/provincial public health guidelines for the most current recommendations
and updates. The Public Health Agency of Canada currently advises travelers to practice enhanced health
precautions when travelling, as COVID-19 continues to circulate in Canada and internationally. The virus
continues to change over time and new variants will continue to appear. So, make sure to consult with your
healthcare team at least 6 weeks before you travel.

Here are two key resources to consult:

• Centers for Disease Control and Prevention (CDC): https://wwwnc.cdc.gov/travel A US-headquartered
organization that maintains up-to-date, global information for travelers.
• Government of Canada website: www.travel.gc.ca Canadian travelers can access information
concerning traveler health, safety notices/advisories, plus advice on a number of topics such as travel
tool kits and receiving medical care in other countries.

Discuss your travel plans with your healthcare team several months before your departure:
• Whether the destination you have in mind is a good choice for you
• What extra precautions you may need to take
• Advice/suggestions about vaccinations, medication, and emergency treatment options
• Re-scheduling or modifying your infusion schedule to make sure you are in good health during your trip

Human Normal Immunoglobulin (10%)

Recombinant Human Hyaluronidase
C-APROM/CA/HYQ/0014
Collect and prepare key health documents that you may need to bring with you:
• Have your doctor fill in and sign the Medical supplies letter – Ask your doctor to include an
explanation about your (or your family member’s) immune deficiency. The letter also lists all medications
and medical equipment you will have to bring with you.
• Vaccination records – You may be required to present COVID vaccination proof, plus other vaccine
requirements for certain destinations. If you have obtained “vaccine exemption” status, you will need
your doctor to fill in and sign the exemption form.
• Other important documents – Bring your doctor’s/clinic contact information and additional information
about your or your family’s health, including healthcare records, and names/dosages of medications.

Prepare a travel kit for your medicines and supplies

• Pack your medicines – Organize the medicines that you will be bringing with you. Speak to your doctor
and get your prescriptions ready ahead of time.
• Pack all of your medical supplies in carry-on luggage – Carry your medicines, such as immunoglobulin
and antibiotics, in your hand luggage for easy access and in case your checked-in baggage is lost.

Prepare for local conditions and take extra precautions to maintain health
• Clothing requirements – Bring extra layers for cool temperatures and/or for protection from the sun.
• Hygiene – Maintain good hygiene conditions to protect from infections.
• Use mosquito repellent – To avoid mosquito-borne diseases like dengue fever or malaria that may be
present in some regions.
• Water supply – Drink bottled water only, as tap water in some areas can cause illness due to bacteria
and different mineral content. Do not drink well water or water from a stream, particularly when
camping, because it may have higher concentrations of bacteria, viruses, or parasites.
• Maintain a healthy diet – People with immune deficiencies are at a higher risk of infections, therefore
maintaining a healthy diet is especially important. Ask your doctor or nutritionist to create a balanced
meal plan that is right for you and based on foods that are available at your destination.
• Exercise and maintain physical activity – Staying physically fit - even when travelling - allows you to be
in the best condition to manage your immune deficiency. Always ask your doctor first before you start a
specific exercise routine.
• Swim with caution, as water in swimming pools and hot tubs may pose a health risk if the water/
pool is not cleaned often enough. Avoid swimming in polluted seas or lakes.

Consult these websites for further travel planning assistance:

• Centers for Disease Control and Prevention (US) – https://wwwnc.cdc.gov/travel (Travelers’ Health section)
• Government of Canada website for travelers – www.travel.gc.ca
• ImmUnity Canada – www.immunitycanada.org/
• Association des patients immunodéficients du Québec – www.cipo-apiq.ca
• Immunodeficiency UK patient organization – www.immunodeficiencyuk.org

Bon voyage,
Your OnePath Team

Human Normal Immunoglobulin (10%)

Recombinant Human Hyaluronidase
C-APROM/CA/HYQ/0014
 If you have any questions, simply contact the
OnePath® Patient Support Program toll-free at:

1-844-MY1-PATH
(1-844-691-7284)
Monday through Friday,
8 a.m. to 8 p.m. EST
Fax: 1-844-951-7284
Email: support@onepathprogram.ca

To whom it may concern,

Please be advised that Name DOB is transporting his/her HyQvia®

medication from Canada for the purpose of having essential treatment while out of the country. This
medication must be kept in a cooler bag to maintain a temperature between 2 to 8˚C and requires the use of
the ancillary supplies for the purposes of self-administration, some of which are listed below:

• HyQvia (Normal Immunoglobulin [Human] 10% and Recombinant Human Hyaluronidase) dual vial unit(s)

• Alcohol swabs, tape, and bandages

• Solution container (bag or syringes(s))

• Non-vented spike(s) or needle(s)

• Subcutaneous needle set(s) with clear dressings

• Infusion pump and pump tubing

• Sharps container

• Treatment logbook

Thank you in advance for your time in this matter.

Physician’s Signature: Date:

Physician Name:
Physician Address:
Physician Phone:
Physician Fax:

C-APROM/CA/HYQ/0015