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Please read and complete this donor packet as thoroughly as possible. If you need assistance, our staff will help you. If you do not know an answer or need clarification to a question, please leave it blank and we will review it with you. Honesty is very important when completing the forms. You will not be judged on your answers. The packet helps us to learn about you and safely guide you through the donor evaluation process. If you have questions, please contact the Transplant Office at (217) 788-3441.


General

Last Name
First/Middle Name
Donating kidney to
How long have you known potential recipient
Height and Weight
Date of Birth
Age
Relationship to potential recipient
Social Security number