Kidney Patient Referral Form

Our Kidney Program

Thank you for contacting the Kidney Program at MedStar Georgetown Transplant Institute! If you do not have an email address or would like to complete this information over the phone, please contact our team at 202-444-3701. If you are a physician, dialysis unit, or a patient looking for more information about transplantation, please fill out only the required fields, marked with a red asterisks.

If you are ready to schedule a transplant evaluation appointment, please fill out the entire form.
Use the Next button at the bottom of the page to continue. Note that the information will not be saved or reviewed until you click Submit on the final page. All information disclosed in this questionnaire is confidential.

A member of the transplant team will contact you shortly.

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Submitter's Information

Referring Person

Form Completed By

Referral Contact First Name

Referral Contact Middle Name

Referral Contact Last Name

Referral Contact Title

Referral Contact Phone Number

Referral Fax Number

Referral Contact Email

Patient Information

Referral Organ

Patient First Name

Middle Name

Patient Last Name

Date of Birth

Gender

US Citizenship

Race

Employment Status

Education

SSN

Height ft in

Weight

Patient Contact Information

Street Address

City

State

Postal Code

Telephone

Additional Patient Information

How did you hear about the MedStar Georgetown Transplant Institute?

Other way (please specify)

Primary Language

Interpreter Needed

Religion

Relationship Status

Emergency Contact Name

Emergency Contact Phone

Emergency Contact's Relationship to Patient

Does Patient have a Potential Donor

Does Patient have a Support Person

Who is the support person

Support person's phone number

Support person's relationship

The myMedStar Patient Portal is a free, secure way to manage your health information, request and view test results or clinic appointments, and communicate with your physician. Can we send you an email to enroll you in the myMedStar Patient Portal?

The MedStar Georgetown Transplant Institute has several clinic locations. Where would you prefer to be seen?

Medical Assessment

Cause of Kidney Disease/Failure

Other Diagnosis

Diabetes?

Any Limitations?

Please detail Limitations

Insurance Information

Health Plan Name

Group Name

Policy Number

Customer Service Phone Number

Subscriber Name

Subscriber Birthdate

Do you have a secondary insurance provider

Second Health Plan Name

Second Group Name

Second Policy Number

Second Customer Service Phone Number

Second Subscriber Name

Second Subscriber Birthdate

Care Coordination

Referring Physician Name

Referring Address

Referring Phone

On Another Transplant List

Name of Transplant Center

Transplant Center Contact Person/Coordinator

Transplant Center Contact Phone

Dialysis

Dialysis Type

Lookup Dialysis Facility

Dialysis Facility Name

Dialysis Address

Dialysis Phone

Dialysis time on machine in hours

Dialysis start time

Dialysis Days

Dialysis initial start date

Social Worker / Care Manager at Dialysis Center

Other Medical Providers

Please list the patient's other physicians and their phone numbers here

Endocrinologist

Endocrinologist Phone

Nephrologist

Nephrologist Phone

Primary Care Provider

Primary Care Provider Phone

Other Providers