Dear Friend:

You have identified yourself as a Miller-Fisher Variant patient.

As you know, putting people in touch with each other is helpful; however, this is done only with their permission. Please fill out the form at the bottom if you wish your name to be included. This is to be shared only by those Miller-Fisher patients on this list. Please return the form at your convenience.

I give my permission to have my name listed to be shared only with those having Miller-Fisher Variant.


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