KIDNEY DONOR EVALUATION FORM

Thank you for your interest in donating your kidney.

All information will be kept confidential. This form is not binding and you can opt out at any time during this process.

Please complete the form below to begin your kidney donation evaluation. If you are a candidate to donate a kidney, you will be contacted by a kidney donor coordinator.

You will need to provide 3 blood pressure readings to be evaluated as a donor. You can complete this information below if you already have it on record. If not, you will need to take your blood pressure on 3 different days and provide it before your first appointment.

Please note, this form will take approximately 15-25 minutes to complete and it cannot be saved during the process. If you would prefer to complete a paper version of this form, please click here to print a paper copy to mail in.

ANY KIDNEY DONOR MUST BE 18 YEARS OF AGE OR OLDER TO BE ELIGIBLE TO DONATE.

PRE-SCREENING

GENERAL INFORMATION

MEDICATION USE AND ALLERGIES

KIDNEY RECIPIENT INFORMATION

Blood Pressure

Medical History

For WOMEN Only

Blood Transfusion and Donation

Travel History

Social History

Family History

General Well Being


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