Kidney and or Pancreas Referral Form Montana - wkhs 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by selecting the type of transplant needed: Kidney, Pancreas, or both. This is crucial for directing your referral appropriately.
3. Fill in the patient information section, including last name, first name, address, and contact details. Ensure accuracy as this information is vital for communication.
4. Complete the emergency contact section with a reliable person's details who can be reached if necessary.
5. Provide dialysis information if applicable. Include the referring physician's name and details about the dialysis center.
6. In the medical information section, detail any relevant health conditions such as diabetes or allergies. This helps in assessing eligibility for transplantation.
7. Lastly, ensure all required documents are prepared and faxed to the provided number to complete your submission.

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