Kidney donor questionnaire Contact details First name Last name Teudat Zehut or Passport Number Year of birth Address City Country ZIP code Telephone Mobile phone Work phone Fax Email Occupation Citizenship Family status ChooseSingleMarriedWidow/er Number of children Medical information Blood type Are you generally healthy? Height Weight Do you suffer from any of the following: High blood pressureKidney DiseaseObesityDiabetes Other Do you take regular medication? Please specify Special requests I hereby confirm that my decision to donate a kidney was made in a fully informed manner and without pressure from any external source. I hereby confirm that I have not requested or received, nor do I have any intention of requesting or receiving any monetary or other compensation for the donation of my kidney (other than reimbursement of expenses as per the transplant law). My kidney donation is strictly altruistic, for the purpose of saving a life. How did you come to "Matnat Chaim"?Please leave this field empty. Send
