LIVE LIVER DONOR FORM

Required Fields *

First Name:

MI:

Last Name:

Date of Birth (mm/dd/yyyy):

Age:

Gender:

Male Female

Address:

City:State:Zip: State: Zip:

This address is out of state:

E-Mail:

Phone (Best Contact #):

Race:

Ethnicity:

What is your blood type?

Name of person you want to donate to:

Your relationship to the recipient:

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."

Name:

Signature

Date:

LIVE LIVER DONOR FORM