Kidney Pancreas Transplant Review And Referral Form (Page 3 of 4) in pdf

Kidney Pancreas Transplant Review And Referral Form Page 3

UNC Center for Transplant Care

Renal/Pancreas Transplant Review and Referral Form

Part I

Pt’s name:__________________________________________

Transplant Surgeon’s Opinion:

I _____Agree_____Disagree with the referring nephrologist’s opinion

I feel this patient is an:_____Acceptable _____Unacceptable _____Marginal Transplant Referral

I_____Agree_____Disagree that this patient should not be considered for renal transplant now or in the future.

__________________________________________

Date:______________

Signature of Transplant Surgeon

Referral Received:

_____Patient will be contacted by UNC Center for Transplant to schedule Renal Transplant Orientation Class.

_____Additional information is required from referring doctor/dialysis center.

__________________________________________________________________________________________

_____Patient previously referred/evaluated. Outcome as follows:

__________________________________________________________________________________________

________________________________________________________ __________________________________

_____Patient not a candidate due to:

__________________________________________________________________________________________

_____ Other:

__________________________________________________________________________________________

February 2015

Kidney Pancreas Transplant Review And Referral Form Page 3