Company Fax (leave blank)

What organ are you interested in donating? *

Kidney

Donation To *

Recipient Name *

If you are not a suitable match for the recipient you registered to donate to, would you consider being in paired exchange? *

If your recipient is no longer in need of transplant, would you consider donating to another patient on the organ donation waitlist? *

Relationship to Recipient *

Please explain your relationship to the patient.

How did you hear about this person's organ donation need? *

How did you learn about the UofL Health Living Donor Program? *

Comments

Do you have health insurance? *

Which insurance provider(s) do you have? *

*This is not for billing purposes

Donor Information

First Legal Name

Last Name

Middle Initial

Gender *

Race / Ethnicity *

Social Security Number *

Date of Birth *

Marital Status *

Blood Type *

Citizenship Status *

Height *

Weight (lbs) *

BMI *

Please use the BMI Calculator to determine your BMI and select your BMI Range

Highest Level of Education *

Age *

Contact Information

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Home Phone

Mobile Phone

Work Phone

When is the best time to contact you?

What is your preferred method of contact?

Email *

Primary Care Physician

Primary Care Physician Phone

History

Do you have a history of Smoking?

Please tell us how much you smoked and for how long

Do you have a history of Cancer?

Please tell us when you were diagnosed with cancer, what type you had, and the treatment you had.

Are you being treated for any of the following (Check all that apply):

High Blood Pressure
Heart Disease
Lung Disease
None of these

How many medications are you on for high blood pressure? *

What does your blood pressure usually run?

Do you have a history of diabetes? *

What kind of diabetes do you have? *

Medications / Supplements

Do you have a history of Hepatitis? *

Are you being treated for Hepatitis?

Do you have HIV? *

Do you have a history of substance abuse?

Is there a possibility that you're pregnant?

Have you ever been pregnant?

Previous Surgeries (include previous transplant donations if applicable)

Have you had two or more kidney stones?

Past Medical History

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