Kidney Recipient Intake Form | Allina Health Kidney Transplant Program

Kidney Recipient Registration Form

Allina Health takes reasonable precautions to provide a level of security appropriate to the sensitivity of the information we collect. Although we use reasonable measures to help protect your information against unauthorized use or disclosure, we cannot guarantee the security of information provided over the Internet or stored in our databases and will not be responsible for breaches of security beyond our reasonable control.

Today's Date

Patient information

* First, Middle, Last Name

* Preferred name

* Date of Birth

* Last 4 digits of Social Security number

* Address

* City, State

* Zip code

Home phone

* Cell phone

Email address

* Preferred form of contact

* Gender

* Marital Status

* Spouse name (if not married enter none)

Blind?

Deaf?

* Languages spoken

* Preferred language

Languages written

* Need interpreter

Country of Origin

Ethnic group

* What is your race?

Employment status & employer

Medical history and information

Have you had a previous transplant?

If yes, where and when was the surgery?

* Are you on dialysis?

Dialysis Unit

Dialysis Phone Number

Dialysis Fax Number

Dialysis Type (either Hemo or PD)

Dialysis Days of Week and Time

* Nephrologist Physician name

* Phone number

* Fax Number

Nephrologist Physician clinic address

City, State

Zip code

* Primary Care Physician name

* Phone number

* Fax Number

Primary Care Physician clinic address

City, State

Zip code

Who is referring you

Referring Physician Name

* Phone number

* Fax Number

Referring Physician clinic address

City, State

Zip code

Emergency contact, if applicable

* Contact Name & relationship to patient

* Primary emergency contact phone number

Insurance information

* Primary insurance name

* Primary insurance ID number

Primary insurance group number

Primary insurance policy holder and relationship

Primary insurance claim address & phone number

* Secondary insurance name

* Secondary insurance ID number

Secondary insurance group number

Secondary insurance policy holder and relationship

Secondary insurance claim address & phone number

Tertiary insurance name

Tertiary insurance group number

Tertiary insurance ID number

Tertiary insurance policy holder and relationship

Tertiary insurance claim address & phone number

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