Follow the steps to complete the referral form accurately.

1. Click ‘Get Form’ button to access the referral form and open it in your preferred online editor.
2. Fill in the date of referral, and provide the patient's complete name in the designated field.
3. Specify the patient's age, weight in kilograms, height in centimeters, and race. Ensure this information is accurate and up to date.
4. Provide the patient's address and contact number. Include their Social Security number and Medicare, Medicaid, or other insurance details if applicable.
5. Complete the section regarding the patient's dialysis unit, including the name, address, and the days they attend dialysis. Specify if the patient is on peritoneal dialysis.
6. Document the date of dialysis onset and the nephrologist’s name and contact number, along with a 24-hour contact number if available.
7. Indicate the patient's diagnosis, any biopsy details, blood type (ABO), and answer the questions regarding hypertension and diabetes.
8. List the patient's allergies and current medications, along with any prior transplant history and transfusion history.
9. Complete the statement sections regarding the patient's candidacy for renal transplantation, with evaluations by their nephrologist, unit coordinator, and social worker.
10. Ensure that the referral includes all necessary documents such as history & physical, recent lab results, and various evaluations, as stated in the requirements.
11. Once all sections are completed, review the form for accuracy. You can then save changes, download, print, or share the form as needed.

Complete the Musc Kidney Transplant Referral Form online to facilitate a timely referral process.