Covid-19 Info

Donor Pre-Screen Form

Fill out this brief form and one of our Donor Advocates will reach out to you within 2 business days.

Name*
First Last
Phone*
Email*
Medical Pre-Screening
The following questions will allow our medical staff to determine if you a medically qualified to become a living kidney donor.
Check an of the following conditions that you have had or are currently experiencing:*
- Kidney Stones
- Kidney Infections
- Cancer
- Family History of Kidney Disease
- Chronic Depression
- Suicidal thoughts
- Other
Personal Information
What motivated you to come forward as a donor?*
I want to donate a kidney but I do not know anyone who needs a transplant.*
- Yes
- No
Is it important to meet the recipient?*
- Yes
- No
I want to donate to a specific individual?*
- Yes
- No
If yes, name of recipient:
How did you learn about Kidneys in Common?
How would your familiy and friends react to your desire to be a living kidney donor?*
Does your faith or belief in a higher power play a role in your decision to be a donor?*