PLEASE VISIT WWW.MEDSTARGEORGETOWN.ORG/LIVINGKIDNEYDONOR TO COMPLETE THIS HEALTH QUESTIONNAIRE
Thank you for contacting the MedStar Georgetown Transplant Institute’s Living Kidney Donor Program! We encourage you to read this entire page before starting the questionnaire.
Please review our attached welcome letter. It will provide you with a general outline of what to expect during your living donor evaluation process. It will also be emailed to you once you complete the questionnaire. There are many steps involved to ensure the safety and well-being of both you and your recipient.
Your information will not be reviewed until you sign and click "Submit" button on the final page. All information disclosed in this questionnaire is confidential.
Please fill in the blanks below. Your information will be saved while completing the questionnaire. You can return to the questionnaire at any time by coming back to this page. Click the blueReturning? arrow in the top right corner of this page and enter your Return Code. It will be necessary for you to open a PDF file to complete your Consent for Evaluation.
DO NOT SUBMIT MULTIPLE COPIES OF THIS QUESTIONNAIRE. If you lose your Return Code, please call or email the donor liaison to retrieve it.
If you do not have an email address, please call the donor liaison for assistance.
Please give yourself 20-40 minutes to complete the questionnaire regarding your medical and personal history. If you are interested in donating to a specific person, please have your recipient’s name and date of birth ready before starting.
At any time during this process you are free to change your mind about proceeding with living donation. We ask that you inform of us of this decision.
When you are ready to begin, click "Next Page >>" below.
Thank you again for contacting the MedStar Georgetown Transplant Institute and for pursuing this wonderful gift! Please do not hesitate to call or email us if you need additional assistance.
Please note that THIS QUESTIONNAIRE IS FOR KIDNEY DONATION ONLY, please contact the living donor liaison for assistance with liver donation questions at 202-444-3714 or 202-444-4559.
Important contact information: Donor Liaison: 202-444-3714 or JonesL2@gunet.georgetown.edu General Transplant Institute Office: 202-444-3700 or 1-800-492-5538 Transplant Institute Fax: 202-444-0899 or 877-680-8193 Attention: LD Coordinator
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