Transplant candidate questionnaire Contact details First name Last name Teudat Zehut or Passport Number Year of birth Address City Country ZIP code Telephone Mobile phone Occupation Work phone Fax Email Kupat Holim Private Insurance (if exists) Citizenship Family status ChooseSingleMarriedWidow/er Number of children Family Contact Phone Medical information Height Weight Blood type Cause of renal failure Type of dialysis Date dialysis began Physician's name In which hospital are you registered for a transplant? Is there a doctor in a transplant center who knows you personally? yesno Are you registered with the National Transplant Center? yesno Are you diabetic? yesno Have you ever received a kidney transplant? yesno Do you have antibodies? yesno Family medical information Tested as a donor? Details Fatheryesno Mother yesno Siblings yesno Spouse yesno Children yesno Others yesno Comments 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 confirm that I am aware that registering with Matnat Chaim does not obligate Matnat Chaim to find a kidney donor. How did you hear about Matnat Chaim?Please leave this field empty. Sendכל הזכויות שמורות למתנת חיים 2015Created by Winsite
