Name
*
First Name
Last Name
Date of Birth
*
-
Year
-
Month
Day
Date
SSN
e.g. 123-45-6789
Today's Date
*
-
Year
-
Month
Day
Date
Calculated Age
Age 75 or greater is outside criteria for consideration of living donation at our center.
show the below if age
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
*
Back
Next
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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Next
Have you ever been diagnosed with any liver disease?
*
Yes
No
Back
Next
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
Bipolar?
*
Yes
No
Schizophrenia?
*
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
*
Are you currently taking any prescription medications?
*
Yes
No
Please list all medications that you are currently taking
*
Submit
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