Living Kidney Donor Referral Form
Renown Transplant Institute
Adult Kidney Transplant Program 75 Pringle Way, Suite 901( J7)
Reno, NV 89502 Phone:( 775) 982-3313 | Fax( 775) 982-8063 livingdonation @ renown. org
Donor Information |
|
|
|
Name( Last, First, MI) |
Birth Date( mm-dd-yyyy) |
Sex [ ] M |
[ ] F |
Email Phone
Address
City
State Zip Marital Status Occupation Height Weight Blood Type( if known) Highest Education
Race
Preferred Language
Do you have any significant medical history that may prevent you from being a living donor? Example: High blood pressure, diabetes, lung disease …( If yes, please provide a brief summary)
Primary Care Provider Today’ s Date( mm-dd-yyyy)
Address Phone
City State Zip
Emergency Contact Phone Relationship
Recipient Information
Intended Recipient [ ] Yes [ ] No If Yes, Name( Last, First, MI)
Birth Date( mm-dd-yyyy) Sex [ ] M [ ] F Relationship Blood Type( if known)
Address
City
State Zip Email Phone Please share your motivation for considering living kidney donation( optional)