Create - Solid Organ Transplant Online Referrals

Online Referrals: Organ Transplant, Dialysis, Surgery

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Patient Information

* Denotes required field

First Name

Middle Initial

Last Name

Date of Birth

Gender

Male Female

Social Security Number

Primary Language

Please Specify

Mailing Address

Apt / Suite / Other

City

State

ZIP Code

County

Phone (Home)

Extension

Phone (Work)

Extension

Phone (Cell)

Height (feet)

Height (inches)

Weight (lbs)

BMI

Lowest documented eGfr; include labs PRIOR to the start of dialysis

Marital Status

Spouse Name

Diagnosis

Allergies

Patient Insurance Information

Primary Insurance Name

ID #

Phone

Group

Employer

Secondary Insurance Name

ID #

Phone

Group

Employer

Medicare Part D Rx Plan Name

Medicare Part D Rx Plan ID

AKDC

Yes No Applied

Referral Information

Primary Care Physician

Phone Number

Fax

Referring Physician

Referral Contact Person

Clinic Name

Clinic Address

Apt / Suite / Other

City

State

ZIP Code

Phone Number

Fax

Specific Physician Requested

Is the Patient on Dialysis?

Yes No

Dialysis Information

Dialysis Type

Schedule

Has the patient missed or signed off early more than three times per month for the last three months?

Yes No

Dialysis Unit Name

Phone

Dialysis Unit Address

Apt/ Suite / Other

City

State

ZIP Code

Has the patient previously received treatment at UAMS?

Yes No

Substance Abuse Concerns?

Yes No

Please Specify

Psychosocial Concerns?

Yes No

Please Specify

Compliance Concerns?

Yes No

Please Specify

Recent Hospitalizations?

Yes No

Confirm BMI

Based on the height/weight information, your patient's BMI is .

Would you like to proceed with these values?

UAMS

4301 West Markham Street
Little Rock, AR 72205
United States

Phone: (501) 686-7000
Email: UAMS | IT Development

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