Be the Bridge Volunteer Form

Join our community of Be the Bridge Awareness Volunteers! Be the Bridge to local healthcare professionals and to ongoing care and resources for their patients with GBS, CIDP and MMN. Once you provide your name and address below, Be the Bridge packets will be mailed to you to be dropped off to your local healthcare professionals, at your convenience.

First Name:

Last Name:

Email:

Condition of Interest

How do you relate to GBS, CIDP or related syndrome?

When do you expect to deliver our information packet to your intended practitioner?

How many medical practitioners do you plan to submit this information to?

Your Address

Street

City

State

Zip Code

Country

Do you have any information for healthcare facility and/or professional you are giving the Be the Bridge packet to? This will allow the Foundation to follow up with additional resources, or questions they may have.

YesNo

Practitioner's Information

The more information you are able to provide us about , the better we will be able to follow up with them and provide better insight into our offerings.

Healthcare Organization:

Organization Type:

Medical Facility Type

Do you know the address?

YesNo

Healthcare Org Address

Street

City

State

Zip Code

Country

Do you know the specific Medical Professional's information?

YesNo

Practitioner Information

First Name

Last Name

Profession

Specialty

Practitioner Email:

How did you hear about the Be the Bridge program?

From a FriendFrom a GBS-CIDP VolunteerEmail from GBS-CIDP FoundationGBS-CIDP Foundation WebsiteInternet SearchSocial MediaOther

Social Media Source

TwitterFacebookInstagramLinkedIn

Other:

Contact Information
Your Rights Under GDPR