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

Kidney Pancreas Transplant Review And Referral Form Page 4

UNC Center for Transplant Care

Renal/Pancreas Transplant Review and Referral Form

Part II

Transplant Referral Information Check Sheet

(This information should be provided with the referral unless

indicated that this patient is not a transplant candidate)

PLEASE NOTE THAT THE FOLLOWING REFERRAL INFORMATION IS

REQUIRED TO INITIATE AND EXPEDITE THE TRANSPLANTATION PROCESS

_____ Completed UNC Hospitals Transplant Review and Referral Form

_____ Recent (within the past 6 months) history and physical, or the referring physician’s initial note, which include s a

comprehensive history and physical

_____ Most recent hospital discharge summary

_____ Most recent EKG and Laboratory values (blood work, UA, C & S if possible)

_____ Results of any consultations obtained within the past 12 to 18 months. For example, cardiac consult to rule out

MI; GI consult to evaluate guiac (+) emesis or any problems that have required additional follow up through

support services

_____ Social Work Assessment

_____ Dietary Assessment

_____ Face sheet of demographics

_____ Copy of insurance cards

_____ 2728 form (if on dialysis)

_____ Documentation of GFR 0f 20.0 or less (if not on dialysis)

_____ PPD results

_____ Any additional information you feel would expedite the care of your patient in the evaluation process

*** We would appreciate one-side only copies****

Thank you!

February 2015

Kidney Pancreas Transplant Review And Referral Form Page 4