Hidden Clinician Information Clinician First Name * Clinician Last Name * Professional Degree(s) * Hospital / Clinic Name * Academic Title Administrative (Clinical) Role Email Address (not public) *
The email address will not be displayed publicly unless entered again below. We will only use this email address for communication regarding this post and other private communication related to the AE Alliance.
Clinic Location Country * Country* United States Afghanistan Albania Algeria American Samoa Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Costa Rica Côte d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France French Polynesia Gabon Gambia Georgia Germany Ghana Greece Greenland Grenada Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Northern Mariana Islands Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Sudan, South Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Yemen Zambia Zimbabwe State * State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Armed Forces Americas Armed Forces Europe Armed Forces Pacific City * Street Address *
Street Address of the Clinic Office (not the mailing address). To be used for mapping clinic location.
Address Line 2
Additional address information such as suite or unit number.
Province/ Territory * Province/ Territory Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Zip Code / Postal Code * Preferred Communication Methods
Please provide a phone number for patients or other clinicians to reach you or your clinic. You may also provide fax, email or another form of communication below. All communications methods you provide in this section will be displayed publicly.
Phone Number *
Clinic phone number to be displayed publicly.
You may provide a fax number to be displayed publicly.
Email (for public use)
You may provide an email address here. It will be displayed publicly.
Web address for clinic or medical center.
You may provide another method of communication here including social media options. Any entries will be displayed publicly.
Areas of Expertise
For the following categories, check all that apply. Please indicate only areas that you have expertise related to Autoimmune Encephalitis treatment.
Choose your medical profession from the drop down menu.
Medical Profession -- select a Profession -- Clinical Psychologist (PhD) Medical Doctor (MD, DO) Nurse Practitioner (NP) Occupational Therapist (OT) Physical Therapist (PT) Physician Assistant (PA) Registered Nurse (RN) Speech and Language Therapist Patient Type(S) * Experience Diagnosing, Treating or Caring for AE Patients *
Have you diagnosed, treated or cared for patients with any of the following types of AE? Check all that apply.
Other Antibody-Positive AE Patients
Please list the antibody types of any other antibody-positive AE patients you have diagnosed, treated or cared for.
Check the boxes that describe your area(s) of medical speciality
Other Medical Speciality
Please enter any additional speciality or subspecialty that you have expertise with.