Name
*
First Name
Last Name
Date of Birth
*
-
Year
-
Month
Day
Date
Biological Sex (sex assigned at birth)
*
Male
Female
Indeterminate
Race/Ethnicity (select all that apply)
*
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Hispanic or Latino
Other
Home address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
Cell Phone Number (SMS Confirmation Required)
*
Height & Weight
*
Do you have health insurance?
*
Yes
No
Health Insurance Information
*
Which organ are you considering donating?
*
Kidney
Liver
Either Kidney or Liver
Do you have a specific recipient you would like to donate to?
*
Yes
No
Please list the name of intended recipient and their date of birth (if available)
*
Example: John Doe, 6/2/2021
Relationship to Intended Recipient
*
Biological: Parent
Biological: Sibling
Biological: Half-Sibling
Biological: Son/Daughter
Biological: Other Relative
Non-Biological: Parent
Non-Biological: Child
Non-Biological: Spouse
Non-Biological: Significant Other
Non-Biological: Relative
Non-Biological: Friend
Non-Biological: Acquaintance
Non-Biological: Other
Unknown
Motivation to Donate
*
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Have you ever had a stroke?
*
Yes
No
Have you ever been diagnosed with any kidney disease?
*
Yes
No
Have you had more than 2 occurrences of kidney stones?
*
Yes
No
Have you ever been diagnosed with diabetes (High Blood Glucose)?
*
Yes
No
Have you ever been diagnosed with HIV?
*
Yes
No
Have you had 2 or more UTI’s (urinary tract infection) in the last 6 months or 3 in the last 12 months?
*
Yes
No
Do you have any autoimmune diseases?
*
Yes
No
Do you have any autoimmune diseases? If yes, list diagnoses
*
Do you take 3 or more blood pressure medications?
*
Yes
No
Do you take 3 or more blood pressure medications? If so, how many?
*
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Have you ever been diagnosed with any liver disease?
*
Yes
No
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Are you willing to accept blood transfusions?
*
Yes
No
Have you ever had a heart attack or coronary stent?
*
Yes
No
Are you pregnant or breastfeeding or gave birth in the last 12 months?
*
Yes
No
Have you ever had Cancer?
*
Yes
No
Have you ever been diagnosed with Melanoma?
*
Yes
No
Has cancer been in remission for 5 years or more?
*
Yes
No
Please list any other cancer history
*
Have you had suicidal thoughts or attempts in the last year?
*
Yes
No
How many alcoholic beverages do you drink in a week?
*
Are you currently taking prescription medication to manage a substance use disorder? (e.g. Suboxone or Methadone)
*
Yes
No
Have you ever been diagnosed with a mental health disorder?
*
Yes
No
Please list any mental health diagnoses
*
Do you use any recreational drugs, legal or illegal?
*
Yes
No
Please list name of substance, how often used, and the date of last use
*
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