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Physician Referral Checklist

To refer a patient to the Johns Hopkins Comprehensive Transplant Center, please complete the appropriate form below and return to us.

In general, we require the following information:

Physician Information

  • Name
  • Address
  • Phone
  • Fax
  • Email

Patient Information

General Info
  • Name
  • Date of Birth
  • Address
  • Phone
  • Social Security Number
  • Insurance Information
Patient’s Medical History and Records
  • Medical History
  • Surgeries / Procedures
  • Devices, including type and settings
Patient Medications
  • Type(s)
  • Dosages
  • Allergies
Diagnostic Test Results
  • Current chest X-ray report
  • PPD (tuberculosis skin test)
  • Mammogram
  • Colonoscopy
  • Stress test and other cardiac information
  • Other information as available
Additional Test for Lung Transplantation
  • Current chest X-ray report and films
  • Current chest CT scan
  • Complete Pulmonary Function Testing

Contact us for more information on referring a patient to Johns Hopkins.

 

Traveling for care?

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Whether crossing the country or the globe, we make it easy to access world-class care at Johns Hopkins.

Maryland 410-614-5700
U.S. 1-410-464-6713 (toll free)
International +1-410-614-6424

 

 
 
 
 
 

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