We appreciate your interest in living kidney donation and ask that you answer the following questions
to begin the process. Our staff will contact you within 10 business days when our medical team has made a decision about the next steps. If you have any questions or would prefer to complete this screening on the phone, please call us toll-free at (888) 822-7892. All information below will be kept secure and only used to determine if you meet initial requirements to be a living kidney donor.

Please fill out the form below. *Starred fields are required.

Potential Donor Name(Required)
Birth Date (must be at least 18 yrs. old)(Required)
Complete Mailing Address(Required)
I would like to be a non directed donor (NDD). An NDD is a potential donor that does not have an intended recipient but wants to donate a kidney to anyone in need of a transplant
Intended Recipient Name (Non-Directed Donors, please enter 'n/a'.)(Required)
Were you born outside of the U.S.?
Have you ever lived outside of the U.S.?
Sex(Required)
Marital Status(Required)
Employed
Please select which applies to you:

Have you ever been diagnosed with any of the following:

Blood sugar problem or Diabetes(Required)
What type of Diabetes do you have?
HIV(Required)
Hepatitis(Required)
Select type of Hepatitis
Tuberculosis(Required)
Meningitis(Required)
High Blood Pressure(Required)
Have you ever had an allergic reaction to IV contrast dye?(Required)
Have you had a blood transfusion in the last 3 months?(Required)
Have you ever had kidney stone(s)?(Required)
Has a doctor ever told you that you had blood in your urine?(Required)
Have you ever had cancer?(Required)
Have you ever been told you have heart or lung disease?(Required)
Did you have children?
If female, have you ever had a complication in pregnancy?
Do you have any of the following? (select all that apply)
Does anyone in your family have Kidney Disease?(Required)
If Yes, please select all that apply:
Do you smoke any tobacco products now?(Required)
Which do you use?
If you do not smoke now, did you in the past?(Required)
Do you have a history of illegal drug use?
Have you tested positive for COVID since the pandemic started?(Required)
If yes, were you hospitalized?
Have you had a COVID vaccine?
Have you had the flu vaccine in the last year?
Have you ever been diagnosed with a psychiatric illness (including depression or anxiety)?
Have you ever attempted suicide?
If Yes, please check all that apply.
How did you learn about donating a kidney to your loved one, or about living donation in general if you are a Non-Directed Donor?

Thank you for considering the gift of life.