Services

Request Consultation

To request an initial consultation with Memorial Transplant Services, please fill out the online form below, or print a transplant patient referral form, complete and fax to 217-788-4606. We accept physician referrals and self-referrals.

Patient Info

Is this a physician referral or self?

Personal Information

First Name
Middle Name
Last Name
Email
Birth Date
Address
City
State
Zip
Home Phone

Patient Medical Information

Nephrologist
On Dialysis
Does patient have a living donor?
List any other transplant facilities patient is listed

Patient Demographics

Height
Weight
Is patient currently a smoker?
Primary Insurance
ID#
Secondary Insurance
ID#

Documentation

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.

Copy of insurance card
Medication List
Progress Notes/H&P
Radiology
Current Lab
Cardiac Testing
Form 2728

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.

Name
Date
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