Transplant candidate questionnaire

    Contact details

    First name*
    Last name*
    gender*
    Teudat Zehut or Passport Number*
    Date of birth*
    Address
    City*
    Country
    ZIP code
    Mobile phone*
    Telephone
    Fax
    Email*
    Family status
    Number of children
    Occupation
    Job
    Preferred language HebrewEnglishArabicFrenchRussian

    Contacts

    Contact Name
    Proximity to the contact
    Mobile contact

    Medical information

    Blood type*
    Height cm*
    Weight*
    The cause of kidney failure*
    Dialysis type
    Starting a dialysis process
    In which hospital are you registered?
    Kupat Holim
    Is there a doctor from the transplant center who knows you personally? If so, who?
    Have you had a kidney transplant before?*
    Previous transplant date
    Do you have antibodies?
    Is the father eligible for donation?
    Is there an impediment for the father to donate - detail*
    What is the reason that the father is not eligible to donate - detail*
    Why is the father not tested? Detail*
    Is the mother eligible to donate
    Is there any impediment to the mother donating - detail*
    Why the mother was not found eligible to donate - detail*
    Why was the mother not tested? Detail*
    Are there any children who are eligible to donate a kidney
    Is there an impediment to the child / children donating, detail*
    Why the child / ren were not found eligible to donate - detail*
    Why is the child / children not tested? Detail*
    Is there a spouse eligible for donation
    Is there a prohibition for the spouse to donate - detail*
    What is the reason that the spouse is not eligible to donate - detail*
    Why is the spouse not tested? detail*
    Are there any sibling (s) eligible for donation
    Is there an impediment for brothers / sisters to contribute?- detail*
    Why the brothers / sisters were not found eligible to donate - detail*
    Why is the sibling not tested? detail*

    Comments, clarifications

    Comments, clarifications
    Special requests:
    I hereby confirm that I am aware that registering with Matnat Chaim does not obligate Matnat Chaim to find a kidney donor.*
    I hereby confirm that I have not been offered nor do I intend to offer any monetary or other compensation for a kidney donation. The donation is altruistic and the only compensation is reimbursement of expenses that the donor receives in accordance with the Organ Transplantation Law.*.
    I hereby declare that I am aware that altruistic kidney donation is only possible after the options of donors from the immediate family have been exhausted*.