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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.

For kidney or pancreas transplant, please call 410-955-5045 and press 1.

In general, we require the following information:

Physician Information

  • Name
  • Address
  • Phone
  • Fax
  • Email

Patient Information

General Information

  • 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

Call us to speak with any member of our transplant team regarding organ and tissue-specific transplants, how to refer a patient or our patient selection criteria.

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