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LIVE LIVER DONOR FORM
LIVE LIVER DONOR FORM
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MI:
Last Name:
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Ethnicity:
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What is your blood type?
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Name of person you want to donate to:
Your relationship to the recipient:
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Parent
Child
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Other blood related family member (aunt, uncle)
Other non-blood related family member (mother-in-law, father-in-law)
Friend
Acquaintance
I have never met this person
Other
I do not have a specific person I want to donate to:
(Check if applicable)
Height:
Feet:
Inches:
Weight (lbs):
BMI:
Please list any medications you are taking:
Please answer yes or no to the questions noted below:
Blood sugar problems/diabetes?
No
Yes
Blood sugar problems/diabetes during pregnancy?
No
Yes
Are you currently being treated for high blood pressure?
No
Yes
Do you take blood pressure medication?
No
Yes
Were you treated for high blood pressure during pregnancy?
No
Yes
Do you have heart problems?
No
Yes
Do you have a history of kidney stones/problems?
No
Yes
Do you have a history of urine/kidney infections?
No
Yes
Do you have a history of liver problems, including hepatitis?
No
Yes
Have you ever had cancer (including skin cancer)?
No
Yes
Do you hold any beliefs that would prohibit you from accepting blood if needed?
No
Yes
Please list previous surgeries:
Do you consume alcohol?
No
Yes
Do you smoke cigarettes?
No
Yes
Do you use illicit drugs?
No
Yes
Psychiatric condition?
No
Yes
Tell us more about the condition(s) you indicated above:
Please list any allergies that you have:
Please list any other chronic medical conditions that you have:
Additional comments regarding your medical history:
*Important Information for Donors*
"I acknowledge that it is a federal crime for any person to knowingly acquire, obtain or otherwise transfer a human organ for anything of value such as cash, property or other valuable consideration, and I affirm that I am not doing so. While I am interested in donating my organ, I understand that I may decline to donate at any time with an expectation of complete confidentiality. My signature indicates that I understand the prior statements, have completed this form voluntarily and without coercion, and that the information I have provided in this questionnaire is truthful, accurate and complete."
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LIVE LIVER DONOR FORM