Living donor evaluation

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Demographic Information

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Gender:

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

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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