Dear “GBS” Patient:

You have identified yourself as having AMSAN/AMAN a form 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 with similar experiences. Any new information we receive concerning AMSAN/AMAN 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 my permission to have my name listed, and to be shared only with AMSAN/AMAN 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