Living Liver Donor

Medical Screening Questionnaire

Thank you for your generosity and interest in helping someone live longer by applying to be a living liver donor at Montefiore-Einstein. Please take the next step by filling out and submitting our medical screening questionnaire.

For more information, please email transplant@montefiore.org or call:­

* Indicates a required field.

Personal Information


Medical History

Please answer yes or no to the questions noted below:

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.

AUTHORIZATION FOR RELEASE AND DISCLOSURE OF HEALTH INFORMATION PURSUANT TO HIPAA

I, or my authorized representative, request and/or permit the disclosure of any pertinent health information by Montefiore Medical Center to facilitate organ donation.

I understand that:

  1. The authorization is voluntary.
  2. I have the right to revoke this authorization at any time in writing, except to the extent that action has already been taken based on this authorization.
  3. Communications may be electronic, such as email and such methods may not always be secure. There is no guarantee, assurance, or warranty of confidentiality.
  4. I agree to hold Montefiore Medical Center harmless from any claims or liabilities that may result from the electronic communications.
  5. This authorization includes disclosure of information that may relate to alcohol use, drug use, mental health, and infectious disease information.

Thank you, again, for your generosity and interest in helping someone live longer by applying to be a living liver donor at Montefiore-Einstein. One of our transplant associate specialists will contact you to discuss your inquiry.