NEUROMUSCULAR CLINICAL LABORATORY     Neuromuscular Disease Center     Department of Neurology     Washington University School of Medicine     Web Site: http://neuromuscular.wustl.edu/ Campus Box 8111, Room IWJ 404 660 South Euclid Avenue; St. Louis, MO 63110 Phone: 314-362-6981; Fax: 314-362-3752

Patient Name (Last, First, Initials):_________________________________________________
Age  ____  | Sex  ____ | Birth Date ______________
Sample Collection Date_______________ | Specimen #_________________
Clinical diagnosis: _____________________________________________________
Physician requesting test: _____________________________ UPIN# ____________
Referring hospital: _____________________________________________________
Name and address for report and/or charges ________________________________________________
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ANTIBODY TESTS and INTERPRETATION REQUESTED

Syndrome Panels	Individual Antibodies
[ ] Motor Neuropathy         IgM vs Co-GM1, asialo-GM1; NP-9;   IgG vs GM1; GalNAc-GD1a	Neuropathy [ ] Motor: Co-GM1; GM1 (IgM & IgG); NP-9 (IgM)                  GalNAc-GD1a (IgG) [ ] MAG (IgM)                          [ ] SGPG (IgM) [ ] GALOP Antigen (IgM) [ ] Sulfatide (IgM & IgG) [ ] GD1b (IgM)                        [ ] GQ1b (IgG) [ ] β-Tubulin (IgM & IgG)        [ ] GT1a (IgG) [ ] Heparan Sulfate (IgM) [ ] Trisulfated Heparin Disaccharide (TS-HDS)   Other IgM:  [ ] GM2;  [ ] GD1a; [ ] asialo-GM1;     [ ] Z-MAG;  [ ] Decorin; [ ] Chondroitin sulfate;     [ ] Histone H3;  [ ] AHS; [ ] GalNAc-GD1a   Other IgG:  [ ] GalNAc-GD1a; [ ] Heparan Sulfate;                         [ ] Lysoganglioside-GM1   Other: [ ] _________________________
[ ] Sensory (± Motor) Neuropathy         IgM vs MAG, TS-HDS & Sulfatide;   IgG vs Sulfatide
[ ] Peripheral Neuropathy         Motor and Sensory Neuropathy Panels
[ ] Sensory Neuronopathy/Neuropathy         IgM vs Sulfatide, GD1b, TS-HDS; IgG vs Sulfatide, Hu
[ ] Demyelinating Neuropathy         IgM vs MAG, GM1, GalNAc-GD1a, β-Tubulin;   IgG  vs β-Tubulin
[ ] Acute Neuropathy:  IgM vs GM1, β-Tubulin, Heparan sulfate         IgG vs GM1, GQ1b, GD1a, GalNAc-GD1a; β-Tubulin	Paraneoplastic disorder (IgG): [ ] Hu; [ ] Yo;     [ ] Ri; [ ] Tr; [ ] Cerebellar immunostaining
[ ] Myopathy: IgM vs Decorin	[ ] Autism/Landau-Kleffner Syndrome variant

 
NOTE: Please send 3 to 5 cc of serum from clotted blood
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Patient Information
Patient Signature: __________________________________________(For release of information)
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Address: ________________________________________________________
City/State/ZIP: ____________________________________________________
Telephone number: ________________________| Social Security #: _____________________________
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Medicare # & Suffix:  _________________________________| In name of: _____________________________
Missouri Medicaid Recipient # (8 digits): ______________________ | In name of: _________________________
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Subscriber name:______________________________________________ | Date of Birth __________________
Commercial insurance company: __________________________________________________________
Mailing address: _______________________________________ City/State/ZIP: _________________________
Employer: _______________________________________________ Employer phone: ____________________
Certificate/ID/SS #: _________________________ Group #:  ________________
Subscriber signature: __________________________________ (For assignment of benefits)             (Rev 4/09 AP)