Living donor evaluation

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All fields are required unless marked optional.

Demographic Information



At which Mayo Clinic location(s) have you received care?

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How would you prefer to be contacted?

Recipient Information

Which Mayo Clinic Transplant Program is your intended recipient listed at?

Which organ do you wish to donate?

Medical History


Blood Type:

Have you ever experienced the following?(Check all that apply.)

Are you currently a smoker or use smokeless tobacco?

Do you drink alcohol?

Any current or past illegal drug use?

Insurance Information