Dear CIDP Patients:

Our records indicate that you have identified yourself as a CIDP patient. The purpose of this “sub-group” is to provide any new treatment information that may become available. In addition, many have been in touch with one another comparing “notes” and forming a unique “CIDP” network.

If you would like to correspond with other “CIDP” patients via mail, telephone, or email, please fill out the form below and return it to us. Include your area code and telephone number.

Of course, these names are to be shared only with those on the list. We take pride in keeping a strict measure of confidentiality with all names.

I give permission to have my name listed, to be shared only with patients having "CIDP".


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