UC Transplant Patient Referral

Transplant Patient Referral Form
Who are you*

PatientPatient's PhysicianOther
Transplant referral type*

KidneyLiverKidneyPancreasHeart
Your Email (verification)*
Your Cell (text verify)*
Patient's Information
First Name*
Last Name*
Biological Sex (assigned at birth)*

MaleFemaleIndeterminate
Age*
Years
SSN*
Height & Weight*
Date of Birth*

YearMonthDay
Patient's Phone Number
Patient's Email
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employment*

Full TimePart TimeNot Working due to DisabilityNot Working by choiceTemporarily unemployedStudentRetired
Medical condition causing organ failure and need of transplant*
Primary diagnosis
Kidney Primary Medical Conditions Examples:
- Glomerular Diseases
- Tabular and Interstitial Disease
- Polycystic Kidneys
- Congenital, Familial, Metabolic Diabetes
- Vascular Diseases
- Neoplasms
- Hypertensive Nephrosclerosis
Liver Primary Medical Conditions Examples:
- Acute Hepatic Necrosis
- Non-Cholestatic Cirrhosis
- Cholestatic Liver Disease/Cirrhosis
- Biliary Atresia
- Metabolic Diseases
- Malignant Neoplasms
Heart Primary Medical Conditions Examples:
- Cardiomyopathy
- Coronary Artery Disease
- Valvular Heart Disease
- Congenital Heart Disease
- Retransplant/Graft Failure
Previous Transplants?*

YesNoUnknown
Information about previous transplants*
Organ, Date, Center
Health Insurance*

YesNo
Information about health insurance*
Health Insurance Company, Effective Date(s), ID#, Group#, Prior Authorization Phone#
Being evaluated or listed for transplant at another center?*

YesNoUnknown
List other centers*
Dialysis*

No Dialysis/Pre-EmptivePeritoneal DialysisHemodialysis
Dialysis Information*
Schedule, Facility, Address, Phone, Fax
Impairment that requires wheelchair or other assistance*

YesNoUnknown
Assistance Required*
Require language interpreter*

YesNoUnknown
Native Language*
Smoking*

Currently smokesHistory of smokingNever a smokerUnknown
HCV treatment*

YesNoUnknown
Active substance abuse*

YesNoUnknown
Substance Abuse Info*
Hepatocellular Carcinoma*

YesNoUnknown
Total Bilirubin
Recent
Creatinine
Recent
INR
Recent
Liver Biopsy
Recent
Current/Referring Physician's Information
Physician's Name*
Physician's name
Physician's Email
Physician's email
Physician's Phone Number*
Physician's phone number
Physician's Fax Number
Physician's fax number
Physician's Address*

Facility/Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Transplant Patient Referral Form

Patient's Information

Current/Referring Physician's Information