Get Contact Form Transplant Recipient - Scripps Health - Scripps

Filling out the Contact Form for Transplant Recipients at Scripps Health is an essential step towards receiving the vital assistance you need. This guide will help you navigate the form with clear instructions and supportive information tailored to ensure accuracy and completeness.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the form and have it open for editing.
2. In the section labeled 'Today's Date', enter the current date when you are filling out the form.
3. Indicate the type of transplant you need by selecting one of the provided options: Liver, Kidney, Kidney/Pancreas, Pancreas Alone, or Pancreas Islet Cell.
4. Provide your reason for organ failure in the specified field.
5. Select your preferred method of contact by checking the appropriate box: Home Phone, Work Phone, Email, Mail, or Cell Phone.
6. Indicate the best time for you to be contacted.
7. In the personal information section, fill in your first name, last name, date of birth, and gender.
8. Provide your address, including city, state, and zip code, and include your home phone number.
9. List your work phone number, race/nationality, cell phone number, height, weight, and citizenship status, selecting from the options provided.
10. Specify your marital status and indicate whether you are currently working. If yes, indicate your employment status (part-time or full-time).
11. Provide details for any primary or secondary insurance, including the name of the insurance company, policy number, and contact phone number.
12. Indicate how you were referred to Scripps Health by circling either Physician, Website, or Other.
13. Fill in the names and phone numbers of your primary physician, hepatologist, nephrologist, and endocrinologist.
14. Indicate if you have had a previous transplant by selecting Yes or No. If yes, provide the type and date of the previous transplant.
15. Mark any significant health problems you may have by checking the relevant boxes.
16. Indicate if you are on dialysis, and if so, provide the name of the dialysis center.
17. If applying for kidney or liver transplantation, indicate whether you have any potential donors by selecting Yes or No.
18. Once you have completed the form, you can save your changes, download it, print, or share your submission as needed.

Take the next step towards your transplant journey by completing the Contact Form online today.