Renown Transplant Institute Initial Referral Form

PATIENT 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 Email: transplant @ renown. org
PATIENT INFORMATION Patient Name( Last, First, MI) Birth Date( mm-dd-yyyy)
Sex [ ] M
[ ] F
Patient Email( optional)
Address
Preferred Language
City
State Zip Code Phone
Previous Transplant [ ] Yes [ ] No
If Yes: List Year and Transplant Center
Currently Listed for a Transplant?
• If yes, please list the transplant center( s): Currently Being Evaluated for a Transplant but Not Yet Listed?
• If yes, please list the transplant center( s):
Name( s) Relationship( s) Potential Living Donor( s) [ ] Yes [ ] No Primary Insurance Secondary Insurance( if available)
REFERRAL INFORMATION
Referral By
Date( mm-dd-yyyy)
Nephrologist
Dialysis Facility( if applicable)
Dialysis / Nephrology Address
City
State
Zip Code
Phone Fax
Modality( if applicable) [ ] HD
[ ] PD [ ] HHD
Dialysis Schedule [ ] M / W / F [ ] T / Th / S [ ] Other:
PCP
PCP Phone
Additional Care Provider( s):( Name and Specialty)
Fax completed form and required records to:( 775) 982-8063
[ ] Insurance Cards( front and back)
[ ] Demographics Sheet
[ ] Most Recent H & P
[ ] Most Recent Nephrology Notes
[ ] Current Medication List
[ ] Most Recent Labs
[ ] Most Recent Hospital Discharge Summary( if available)
[ ] Vaccination Records
[ ] CMS 2728 Form( required for ESRD patients)