Dear “GBS” Patient:

You have identified yourself as being “Wheelchair Limited” as a result of Guillain-Barre Syndrome. We have developed a “sub-group” for these patients. The benefit of this group is to be in touch with others in a similar situation. Any new information we receive concerning this level of recovery will be passed on to you immediately.

Please complete the permission slip below which allows your name to be shared with others. Of course, these names are to be shared only with those on the list. We take pride in keeping a strict measure of confidentiality.

Please return the form at your earliest convenience.

I give permission to have my name listed, to be shared only with other "Wheelchair Limited" patients.


Name:___________________________________________________________ Age: __________


Address: _______________________________________________________________________


City: _____________________________________________State:__________ Zip: ___________


Phone: (__________) ______________________ - ______________________________________


Email: __________________________________________________________________________


Signature: ________________________________________________________________________



Please mail or fax this form to the information below:

GBS/CIDP Foundation International - The Holly Building - 104 1/2 Forrest Ave. - Narberth, PA 19072
Phone: 610-667-0131 - Fax: 610-667-7036 - www.gbsfi.com - E-mail: info@gbsfi.com