UPMC Transplant Services

What organ are you interested in donating?

Do you have health insurance?

Which insurance provider(s) do you have?

UPMC BCBS Optum United Cigna Aetna Medicare Medicaid Other

Insurance ID number

Insurance Policy number

Insurance Group number

Insurance Subscriber

Relationship to Insurance Subscriber

Insurance Subcriber's DOB

Id #	Policy #	Group #	Subscriber	Relation to Subscriber	Subscriber Dob

Last Name

First Name

Middle Initial

Gender

Height

Weight (lbs)

Blood Type

Date of Birth

/

Marital Status

Country

Address Line 1

Address Line 2

City

State

Zip Code

Address

Home Phone

Mobile Phone

Work Phone

Email

Do you have a history of Smoking?

How Long?

Quit?

When?

Are you willing to Quit?

Do you have a history of Cancer?

Type?

Please specify

Are you being treated for any of the following (Check all that apply):

High Blood Pressure

Heart Disease

Lung Disease

What does your blood pressure usually run?

Do you have a history of diabetes?

Are you using insulin?

Medications / Supplements

Do you have a history of Hepatitis?

Type?

A B C

When Diagnosed?

Do you have a history of IV Drug use?

When?

Do you have a history of non-prescription or recreational drug use?

When?

How many drinks of Alcohol do you consume per week?

Number of Known Pregnancies?

Previous Surgeries (include previous transplant donations if applicable)

What is your employment status

Do your daily activities require you to lift more than 10 pounds daily?

Do you have time to take off for recovery?

How much time can you afford to take off for your recovery?

Will you have support during your recovery time?

UPMC Transplant Services

Living-Donor Kidney Transplant at UPMC