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.

Patient information

Medical history and information

Who is referring you

Emergency contact, if applicable

Insurance information