Patient Enrollment Form

Tell us about you

We use this information to connect interested donors on your behalf to the right donor intake form to start the testing process.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Transplant Center
Enter the name exactly as it appears on your paperwork
NKR Microsite URL (if you have one)
If you have already created your NKR microsite, paste the link here. If not, leave this blank.
How would you like us to refer to you in community outreach? (hover for more details)

Designate your Champion

A Champion is a trusted person in your life — a spouse, sibling, adult child, or close friend — who advocates on your behalf. Their job isn't to ask anyone to donate. It's simply to invite people to learn at an upcoming Kidney Convo. If you designate a Champion, we'll send them everything they need to get started.
Would you like to designate a Champion?

Champion Full Name

First NameLast Name
Champion Email
example@example.com
Champion Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
If there is a personal message you'd like to include in the email to your Champion? If so, write it here.

Reaching out to faith-based communities

If you share your faith community's information with us, we'll reach out directly to a contact there and ask them to share an invitation for A Kidney Convo with their congregation. We'll handle the entire conversation — you don't need to say a word to anyone. Please know that while we will always make the ask, we cannot guarantee that every faith community will choose to share this with their members. Filling out this section does not guarantee your faith community will participate. But for those that do, their community will hear about living kidney donation in a supportive, no-pressure setting, and anyone who feels called to learn more can take the next step on their own.
Do you have a church/synagogue/mosque/place of worship you'd like us to reach out to?
If you don't have a faith community to add, you can still share personal contacts on the next page.

Tell us about your Faith Community
Faith Community Name
Required
City/State
Required
Website
If your faith community has a website, add it here. If not, leave this blank.
Who is a good contact person for us to reach out to?
Contact Person full name
Contact Person role
What is the person above's role in the faith community?
Contact person email address
example@example.com- double check this is entered correctly!
Contact person phone number (or main phone line)
Please enter a valid phone number.Format: (000) 000-0000.

People You'd Like Us to Reach Out to Directly
If there are people in your life who might want to learn more about living kidney donation, share their information below and we'll reach out to them personally with information about A Kidney Convo. Great contacts to think about include friends, family members, coworkers, neighbors, or anyone in your personal community who you think might be open to learning more.

Please note: in order for NSNO to take action on your behalf, you need to have submitted at least one church or one direct contact in this form. If you selected No to both sections, we won't have anyone to reach out to and won't be able to move forward.

Here is exactly what they will receive:
Do you have anyone you'd like us to reach out to directly?

Share the people you'd like us to reach out to

Add as many or as few contacts as you'd like — even one makes a difference. These should be people in your life who you think might be open to learning more about living kidney donation. You only need their name and email address. We'll take it from there.
If there is a personal message you'd like to include to all of these contacts, please write it here. As a note, the same message will be sent to all the contacts below. (OPTIONAL)
Optional
Contact Name

First NameLast Name
Contact Email
example@example.com
Contact Name

First NameLast Name
Contact Email
example@example.com
Contact Name

First NameLast Name
Contact Email
example@example.com
Contact Name

First NameLast Name
Contact Email
example@example.com
Contact Name

First NameLast Name
Contact Email
example@example.com
Contact Name

First NameLast Name
Contact Email
example@example.com
Contact Name

First NameLast Name
Contact Email
example@example.com
Contact Name

First NameLast Name
Contact Email
example@example.com
Contact Name

First NameLast Name
Contact Email
example@example.com
Contact Name

First NameLast Name
Contact Email
example@example.com
Do you have more contacts to add?

Tell us about you