Specimen Request Form

  UM/NPF Brain Endowment Bank™

NEUROPATHOLOGICAL TISSUE SPECIMENS REQUEST FORM

Date of Request
Description of Cases (Diagnosis, i.e., non-neurological, Parkinson's, Alzheimer's, Etc.)
Number of Cases
Region(s) of Interest
Autolysis (Range/Hours)
Age (Range)
Special Handling/Fixation (attach protocol if applicable)
Description of Research Study
Source of Support (PHS Number and Title)
Dates of Project Period

FORWARD TO

Name
Title
Address
City/State/Zip
Telephone
FAX
Email Address
Federal Express Billing Number

Please acknowledge in publications the UM/NPF Brain Endowment Bank™, which is funded by the National Parkinson Foundation, Inc., Miami, FL and other private donations.
In order to confirm that you have read and agree to the above, please type ''AGREE'' in the box: