Living Organ Donation Inquiry Form

If you would like to talk to someone in the UW Health Transplant Program in Madison, Wisconsin, about the possibility of becoming a living kidney donor, we would be happy to contact you. Please complete the form below and someone from the program will contact you shortly.
 

If you are interested in living liver donation, please note that we do not have a non-directed living liver donation program. We do have a non-directed living kidney donation program.

 

Email is not a highly secure means of transmitting health information. You may transmit this form via fax or mail if you prefer. By transmitting this completed form you authorize UW Hospital and Clinics to use this data for purposes related to treatment, research and operations.

 

* = required field.

 

Donor Information

 
Name (First and Last) *
 
Date of Birth (MM/DD/YYYY) *
 
Phone Number (Include Area Code) *
 
Email Address *
 
Address *
 
City, State, ZIP Code *
 
Gender:
 
When do you prefer to be contacted?
 
Do you know your intended recipient?
 
If yes, please enter the recipient's name and your relationship: *
 

Medical History

 
Height (feet and inches) *
 
Weight *
 
Body Mass Index | Calculate Your BMI *
 
Please check the boxes corresponding to any conditions for which you have received treatment or a past diagnosis:
 
 
If you checked any of the previous, please explain:
 
 
Please describe any other medical problem or diagnosis not listed above:
 
 
Please list all current medications:
 
 
Please list all past surgeries:
 
 

Note: If you would like to submit this form via fax or U.S. Mail, please select print from your web browser menu now, and do not click on the submit button below.

  
 

 

If you prefer to submit this information by fax or U.S mail, you may print the form after you complete it and send to:

 

Fax

ATTN: Mandy McGuire

(608) 262-5624

 

Mail

UW Transplant Program

ATTN: Mandy McGuire

600 Highland Avenue, F8/177
Madison, WI 53792-1735