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 INTERPRETATIONS REQUESTED

Syndrome Panels Individual Antibodies
[ ] Motor Neuropathy
        IgM vs: GM1, asialo-GM1; NP-9; GalNAc-GD1a; NS6S; MAG
          IgG vs: GM1; GalNAc-GD1a
Neuropathy
  [ ] GM1 (IgM); [ ] GM1 (IgG)
  [ ] MAG (IgM)
  [ ] SGPG (IgM)
  [ ] GALOP Antigen (IgM)
  [ ] Sulfatide (IgM & IgG)
  [ ] GD1b (IgM)
  [ ] GQ1b (IgG)
  [ ] β-Tubulin (IgM & IgG)
  [ ] GT1a (IgG)
  [ ] Heparan Sulfate (IgM)
  [ ] TS-HDS (IgM)
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, GD1b, TS-HDS & Sulfatide;   IgG vs: Sulfatide
 
[ ] Peripheral Neuropathy
        Sensory Neuropathy + GM1
 
[ ] Sensory Neuropathy/Neuronopathy
      IgM vs: MAG, GD1b, TS-HDS & Sulfatide;   IgG vs: Sulfatide & Hu
 
[ ] Demyelinating Neuropathy
        IgM vs: MAG, GM1, GalNAc-GD1a, β-Tubulin;  IgG vs: β-Tubulin
 
[ ] Acute NeuropathyIgM 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.
For data without interpretations, please contact us.
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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 6/10 AP)