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Kidney and Pancreas Transplant
Kidney and Pancreas Transplant
Kidney and Pancreas Transplant
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Kidney and Pancreas Self Referral Form
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Nazih Zuhdi Transplant Institute
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Kidney and Pancreas Transplant
Our Providers
Procedure
Criteria List
Kidney and Pancreas Self Referral Form
Kidney Living Donor
Patient Orientation Videos
Kidney Corner Podcast
Patient Resources
Nazih Zuhdi Transplant Institute
Phone
405-949-3816
888-949-3816
Address
3400 N.W. Expressway
Building C, Suite 700
Oklahoma City, OK 73112
GET DIRECTIONS
Kidney and Pancreas Self Referral Form
* Required fields
* First Name
* Last Name
* Email
* Home Phone
* Cell Phone
Work Phone
* Address 1
Address 2
* City/Town
* State
* Zip Code
INTEGRIS Health may contact me
* Date of Referral
* SSN
* Date of Birth
* Marital Status
Single
Married
Divorced
Widow
* Gender
Female
Male
* Insurance Company Name
* Insurance Subscriber Number
* Insurance Group Number
* Have there been any non-compliance concerns in the last 3 months?
Yes
No
If yes, please explain
* Is this referral for:
Kidney only
Pancreas only
Kidney and Pancreas
* Referring Nephrologist
Address
City
State
ZIP
Phone
Fax
* Cause of ESRD
* Does patient have Indian Health Services?
Yes
No
* Is the patient on dialysis?
Yes
No
If yes, provide date started
Dialysis Center
Address
City
State
ZIP
Phone
Fax
Type
Hemodialysis
PD
Schedule
If patient is on Dialysis, Please provide: Psychosocial History
Check patient's special needs
Illiterate
Deaf
Blindness
Does not speak English
Upon completion of this form, please fax the following documents to 405-815-6404: CMS 2728, drivers license, social security card, insurance card(s), history and physical from your nephrologist.
