Peer Connect Registration

Do you have questions about transplant? Would it be helpful to talk with someone who has been through transplant? Peer Connect matches you with a transplant recipient or caregiver to share their stories and help answer your questions about transplant. These trained volunteers are available by phone or email. We match program participants with volunteers who are similar in age, transplant role (patient or caregiver), and diagnosis (disease or disorder). To do so, we’d like to ask you a few questions.

Select
Caret IconCaret symbol

Demographic Information

We'd like to collect some basic information such as first and last name, contact information, and communication preference.

Select or enter value
Caret IconCaret symbol
Select or enter value
Caret IconCaret symbol
10. Communication preference:*
13. You are a:*
14. If caregiver, your relationship to the patient:
16. Your gender:
18. Patient's gender:

The following questions ask about the patient's diagnosis (disease or disorder). We'd also like to know about the patient's transplant stage, center, and type (if known).

Select or enter value
Caret IconCaret symbol
21. Patient is:*
23. Type of transplant:*

We ask the last few questions to make sure we can best serve everyone in our community. If you do not wish to answer these questions please select ‘prefer not to answer’.

24. Your ethnicity:*

Select all that apply.

Select or enter value
Caret IconCaret symbol
26. Your highest level of education:*

Internal purposes only.

If you're a patient or caregiver, please leave the box empty and select 'Next' below. If a NMDP BMT Patient Navigator completed this form for a participant, enter your name below and note if this was a BRC request:

Privacy Notice|Report Abuse