Get the free Kidney Transplant Referral Recipient Form.pdf - UnityPoint Health

Date of Referral (office use only):. Kidney Transplant Referral Recipient. Patient Information. First Name: MI: Last Name: Phone: Alternative: ...

How to fill out kidney transplant referral recipient

How to fill out a kidney transplant referral recipient:

1. Obtain the necessary referral form from your healthcare provider or transplant center. This form is typically specific to the transplant center where you plan to receive treatment.
2. Begin by providing your personal information. This includes your full name, date of birth, gender, social security number, address, and contact details.
3. Next, provide your medical history. This includes any past or current medical conditions, surgeries, medications, and allergies. It is important to be thorough and honest when disclosing this information to ensure the transplant team has a comprehensive understanding of your health.
4. Indicate the reason for your referral. In this case, you would specify that you are seeking a kidney transplant as a recipient.
5. Include details about your current kidney function. Provide information on your estimated glomerular filtration rate (eGFR), which is a measure of how well your kidneys are functioning. You may need to have recent blood work or other tests to obtain this information.
6. If you have a potential living donor, disclose their information in the referral form. This includes their relationship to you, their full name, contact details, and any relevant medical history.
7. Provide any additional information requested on the form. This may include questions about your insurance coverage, financial information, and support system.

Who needs a kidney transplant referral recipient?

1. Individuals who are suffering from end-stage renal disease (ESRD) and have exhausted other treatment options may need a kidney transplant referral recipient.
2. Patients who are experiencing significant kidney dysfunction, leading to complications such as high blood pressure, fluid retention, and anemia, may be candidates for a kidney transplant referral recipient.
3. Individuals who are not eligible for dialysis or have a poor prognosis on dialysis may require a kidney transplant referral recipient.

It's important to note that the specific criteria for needing a kidney transplant referral recipient may vary depending on the transplant center and individual patient circumstances. Consulting with a healthcare provider or transplant center is necessary to determine if a referral is appropriate.

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