NEUROMUSCULAR CLINICAL LABORATORY     Neuromuscular Disease Center     Department of Neurology     Washington University School of Medicine Campus Box 8111, Room IWJ 404 660 South Euclid Avenue; St. Louis, MO 63110 Phone: 314-362-6981; Fax: 314-362-2826

Patient Name (Last, First, Initials):___________________________________________
Clinical diagnosis: ____________________________________________________
Physician requesting test: _____________________________ UPIN# ____________
Referring hospital: __________________________________________________
Name and address for report and/or charges ____________________________________________________
                                                                    ___________________________________________________________
See: Instructions for sending serum ||   ___________________________________________________________
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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	[ ] Motor: Co-GM1; GM1 (IgM & IgG); NP-9 (IgM)                  GalNAc-GD1a (IgG)
	[ ] MAG (IgM) [ ] GALOP Antigen (IgM) [ ] Sulfatide (IgM & IgG) [ ] SGPG (IgM) [ ] GD1b (IgM) [ ] GQ1b (IgG) [ ] β-Tubulin (IgM & IgG) [ ] Histone H3 (IgM) [ ] Trisulfated Heparin Disaccharide (TS-HDS)
[ ] Sensory (± Motor) Neuropathy         IgM vs MAG, GalNAc-GD1a & Sulfatide;   IgG vs Sulfatide
[ ] Peripheral Neuropathy         Motor and Sensory Neuropathy Panels
[ ] Sensory Neuronopathy/Neuropathy         IgM vs Sulfatide, GD1b, GalNAc-GD1a; IgG vs Sulfatide, Hu	Paraneoplastic (IgG)     [ ] Hu; [ ] Yo;  [ ] Ri; [ ] Tr     [ ] Cerebellar immunostaining
[ ] Demyelinating Neuropathy         IgM vs MAG, GM1, GalNAc-GD1a, β-Tubulin;   IgG  vs β-Tubulin	Other IgM:  [ ] GM2;  [ ] GD1a; [ ] asialo-GM1;     [ ] Z-MAG;  [ ] Decorin; [ ] Chondroitin sulfate;     [ ] Heparan Sulfate;  [ ] AHS; [ ] GalNAc-GD1a
[ ] Acute Neuropathy:  IgM vs GM1, β-Tubulin, Heparan sulfate         IgG vs GM1, GQ1b, GD1a, GalNAc-GD1a; β-Tubulin	Other IgG:  [ ] GalNAc-GD1a; [ ] Heparan Sulfate;                     [ ] Lysoganglioside-GM1
	[ ] Autism/Landau-Kleffner Syndrome variant
[ ] Myopathy: IgM vs Decorin	Other: [ ] _________________________

 
NOTE: Please send 3 to 5 cc of serum from clotted blood
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PATIENT INFORMATION
Patient Signature: __________________________________________(For release of information)
Age  ____  | Sex  ____ | Birth Date ______________ | Sample Date_______________ | Specimen #____________
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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:_________________________________________________
Commercial insurance company: __________________________________________________________
Mailing address: _______________________________________ City/State/ZIP: _________________________
Employer: __________________________________________________ Employer phone: ____________________
Certificate/ID/SS #: _________________________ Group #:  ________________
Subscriber signature: __________________________________ (For assignment of benefits)             (Rev 10/03 AP)