Patient Medical Information
If you have any of the following documentation, please upload with your request below.
If you do not have these documents to attach to this online request for consultation, please fax them to (217) 788-4606. Please make sure that all documents have the patient's name and DOB on them.
If this is a self-referral, we will contact your physician to secure these necessary documents prior to consultation.
I request to be scheduled for an appointment for transplant evaluation at Memorial Medical Center. I hereby authorize Memorial Transplant Services to access by clinical and financial records limited to information pertaining to my care as a transplant patient.