Kidney Recipient Referral Form

Patient Information

Patient's First Name*

Patient's Last Name*

Patient's Maiden Name

Primary telephone number

Phone

Date of Birth*

Patient's Age*

Patient's Gender*

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If Other Please Specify*

Preferred Language*

Height*

Weight*

Referring Information

Patient Referral Type*

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Self or Referred by Healthcare Team*

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Referring Provider Name and Contact Phone Number*

Patient Demographics

Address*

City*

State*

Zip Code*

Country*

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If not USA, What Country?

Is the patient a US Citizen?*

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Medical Information

Do You/Does the Patient Take Insulin?*

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Cause of Kidney Disease?*

Is the patient being treated for active cancer?*

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Any Active Infections?*

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Listed at Another Center?*

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If Listed Elsewhere, Where?

Previously Referred to Maryland?*

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Previous Transplant Information

Previous Transplant?*

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If yes, What Organ was Transplanted?

If yes, Where Was the Transplant Performed?

Patient's Dialysis Information

Is the patient on Dialysis?*

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If yes, when did the patient start Dialysis?

Dialysis Center Name

Dialysis Center Phone Number

Social Information

Martial Status*

Employment Status*

Employer*

Insurance Carrier*

Living Accommodation*

Do you have a living donor?*

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Any Additional Comments

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