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Kidney Transplant Evaluation Referral


Before scheduling an appointment for your patient, please complete the following form and fax it along with the required medical records below. If you have questions, please call the clinic at: (415) 353-1551.

Fax Cover Sheet / Referral Form

Kidney Transplant Fax Cover Sheet & Referral Form Required

This is a single interactive document (Adobe PDF) which can be filled out in your web browser, saved to your desktop and/or printed.

Required Medical Records

Please fax the following documents and medical records in the order as shown below.

For All Patients

  • Nephrologist Notes
  • History & Physical
  • Labs (including crea/GFR, HCV Ab, HIV)
  • Medication List
  • PPD skin test
  • Radiology (Chest x-ray, Abdominal Ultrasound, etc.)
  • Cardiac Testing (Echo, Stress test/myocardial perfusion, Cardiac Catheterization and/or EKG)
  • Consult notes (Cardiology, Oncology, etc.)
  • Insurance card (s) – both sides
    • HMO authorization, if required

Additional Medical Records for Patients on Dialysis 

  • Form 2728
  • Social Worker Notes
  • Dietitian Notes

CDs/DVDs of Imaging Studies

CDs/DVDs of CT/MRI/PET/Ultrasound etc. should be mailed to:

Kidney & Pancreas Transplant Clinic
Attn: New Referrals
400 Parnassus Ave., 7th Floor
San Francisco, CA 94143

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