Transplant Surgery Referral

The Lehigh Valley Institute for Surgical Excellence Transplant Center has more than 30 years of transplant experience and a 94% success rate for kidney transplants.

If you need liver, kidney and/or pancreas services, you or your referring physician may complete the following form to register at Lehigh Valley Health Network's Liver, Kidney and Pancreas Transplant Program. At this time, only the demographic information is required. All other questions are optional, however, helpful for the initial appointment.

The following collected information is protected health information within our secure platform.

Who is filling out the form:

Patient

Provider

Other

Patient Demographics

Name (Legal):

Date of Birth:

Preferred Language:

Do you require Interperative Services?

Yes

No

Address:

City:

State:

Zip Code:

Preferred Phone:

Work Phone:

Mobile Phone:

Preferred Contact #:

Home

Work

Mobile

Email

Email Address:

Nephrologist (if applicable):

Phone #:

Hepatologist (if applicable):

Phone #:

Does patient smoke?

Yes

No

Covid Vaccination status?

Consult Request (if applicable)

Physician Requesting Consultation:

Physician Address:

Phone:

Fax:

Cause of organ failure:

Hypertension

DM I

DM II

Polycystic

FSGS

Other (Specify)

Other (Specify):

Reason for Referral:

Transplant Surgery

Access

Other

Other (Specify):

Dialysis (if applicable)

Dialysis Center:

Phone #:

Dialysis Schedule:

M/W/F

Tu/Th/Sat

PD

Dialysis Start Date:

Shift:

1st

2nd

3rd

Insurance Information

Primary Insurance Plan:

Effective Date:

Subscriber:

ID #:

Secondary Insurance Plan:

Effective Date:

Subscriber:

ID #:

Prescription Coverage Plan:

Effective Date:

Subscriber:

ID #:

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