Atrium Health Charlotte Living Kidney Donor Questionnaire

Living Kidney Donor Questionnaire

Please review this documentation for more information on being a potential kidney donor BEFORE COMPLETING THE FORM BELOW. Potential Kidney Donors

* = Required

Please note: Please note: This form resets after 5 minutes of no activity. This form will take approximately 20 to 30 minutes to complete.

Donor Information

MM/DD/YYYY

Donor Contact Information:

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Emergency Contact Information:

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Primary Care Doctor:

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Medical History:
Have you ever been diagnosed with any of the following?
Social History
Additional Information
Recipient Information

MM/DD/YYYY

Acknowledgement

Current National and Program specific transplant recipient outcomes are updated every six months and the data can be found on the Scientific Registry of Transplant Recipient at srtr.org. There currently are no national or center specific outcomes for living donors calculated by the Scientific Registry of Transplant Recipient. If you have questions about this data or how to use the website, you can discuss this with your living donor team member.

I have read and understand the patient educational material presented to me for potential living donors. I have answered these questions to the best of my ability and without coercion. I understand that I can change my mind at any time about being a living donor. I would like to proceed with my evaluation if I am an appropriate candidate.