Liver Patient Referral Form

Our Liver Program

Liver Care, Liver Transplantation, and Liver Living Donation

Thank you for contacting the Liver Care and Transplantation programs at MedStar Georgetown Transplant Institute!

Physician referrals and patients looking for more information about our liver care and transplantation program, please only fill out the required fields marked with red asterisks. If you would prefer to call, please contact us at 202-444-0766.

If you are ready for a liver consultation and would like to expedite the referral process with one of our liver specialists, please complete the entire form or contact us at 202-444-0766.

If you are considering living liver donation, please complete the entire form or contact us at 202-444-1360.

Use the Next button at the bottom of the page to continue. Note that the information cannot be reviewed until you click Submit on the final page. All information disclosed in this questionnaire is confidential. A member of the liver team will contact you soon after you click Submit.

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Submitter's Information

Referring Person

Form Completed By

Referral Contact First Name

Referral Contact Middle Name

Referral Contact Last Name

Referral Contact Title

Referral Contact Phone Number

Referral Contact Fax Number

Referral Contact Email

Patient Information

Referral Organ

Patient First Name

Middle Name

Patient Last Name

Date of Birth

Gender

US Citizenship

Race

Employment Status

Education

SSN

Height ft in

Weight

Patient Contact Information

Street Address

City

State

Postal Code

Telephone

Additional Patient Information

Primary Language

Interpreter Needed

Religion

Relationship Status

Emergency Contact Name

Emergency Contact Phone

Emergency Contact's Relationship to Patient

Does Patient have a Potential Donor

Does Patient have a Support Person

Who is the support person

Support person's phone number

Support person's relationship

How did you hear about the MedStar Georgetown Transplant Institute?

Other way (please specify)

The MedStar Georgetown Transplant Institute has several clinic locations. Where would you prefer to be seen?

Medical Assessment

Referring Diagnosis

Other Diagnosis

Allergies

Any Limitations?

Please detail limitations

Insurance Information

Health Plan Name

Health Plan ID

Group Name

Policy Number

Customer Service Phone Number

Subscriber Name

Subscriber Birthdate

Do you have a secondary insurance provider

Second Health Plan Name

Second Health Plan ID

Second Group Name

Second Policy Number

Second Customer Service Phone Number

Second Subscriber Name

Second Subscriber Birthdate

Care Coordination

Referring Physician Name

Referring Address

Referring Phone

Comments

On Another Transplant List

Name of Transplant Center

Transplant Center Contact Person/Coordinator

Transplant Center Contact Phone

Other Medical Providers

Please list the patient's other physicians and their phone numbers here

Gastroenterologist

Gastroenterologist Phone

Hematologist

Hematologist Phone

Homecare Company

Surgeon

Surgeon Phone

OBGYN

OBGYN Phone

Primary Care Provider

Primary Care Provider Phone

Other Providers

Medical Information

Please tell us if the patient has any of these conditions:

Diabetic

Hypertension (High blood pressure)

Any metal in body

Claustrophobia

Pacemaker

Alergic to Shellfish

Alergic to iodine

Diagnostic Testing

Please tell us if the patient has completed any of these tests:

Abdominal Imaging

Abdominal Imaging Date Completed

Abdominal Imaging Facility/Location

Cardiac Testing

Cardiac Testing Date Completed

Cardiac Testing Facility/Location

EGD

EGD Date Completed

EGD Facility/Location

Colonoscopy

Colonoscopy Date Completed

Colonoscopy Facility/Location