Miami I Jackson � tlFAf.Tli SYSTEM Tr��g:J I��-

Dear Family and Friends,

As you may or may not know, l have kidney failure, and m}' doctor has recommended that I get a kidney transplant. This is the best option for me to have a better and longer life. A transplant from a deceased donor is a possibility, but could take many years. More than lOD,000 people are on the waiting list fora deceased donor kidney, and there is a very limited supply of donors,

A living donor kidney transplant has a lot of benefits. A kidney from a living donor is usually the best quality kidney. It begins to function more quickly after transplant and lasts longer and works better than kidneys from deceased donors.

You may think my donor has to bea family member. Actually,anyone can be a donor as long as our blood types are compatible, Also, the donor cannot have diabetes, high blood pressure or kidney problems of their own.

Uving donor transplant surgery can be scheduled at a time that is convenient for both my donor and me. Most kidney donor surgeries are performed laparoscopically, In which three or four small incisions are made to remove the kidney, Most donors are able to leave the hospital in two to three days and generally return to work in three to six weeks.

Although this Is hard for me to ask, if you feel this is something you could do, please consider becoming a living donor for me. l fully understand that this is a personal decision that isn't right for everyone. Please know that if you don't feel comfortable with living donation, it will not affect our relationship in anyway.

lfyouwould like more Information about living kidney donation, please contact Miami Transplant Institute's kidney living donor team at 305-355-5000 for general lnformation. They Will be happy to answer any questions you may have, They also offer living donor kidney transplant question-and-answer sessions to help address questions and provide education for potential living donors and recipients.

To begin the process, please return the attached referral and pre-screening form along with a government issued photo identification via fax to 305-355-5368 or email MTlReferral@Jhsmlami.org.

As always, thank you for your caring and concern.

Sincerely,

1801 N,W. 9th Avenue Miami, FL 33136

wwv,,·.MiamiTransplantorg

Office: 305-355-5000 Fax: 305-355-5368

Jeanie HoSang

Miami Transplant

Institute

Name (a; Hsted on driver's licen;eJ

Mailing addnm

City

Children (ages)

Currently employed: 0 No o Yes

Relationship to recipient

Insurance Company Name

Subscriber

Primary care Physician Name/Number

Recipient Name

Nephrology Group

Medication/Dosages

Cancer Screenings

1801 N.W. 9th Avenue MLWI.L, Ft 33136

Living Donor Referral/Pre-Screening Fonn

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recipient?

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Paired Donation?

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Do you take any herbal products? Jf so, Itst the names.

Office: 305�3 55- 5000

Fax: 305,355-5368

www.Mi.amiTramplant.org

Miami Transplant

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Pap Smeai, D No OYes Date:_

PSA ONo DYes Date:

If you are a female, is tbere any cb.ang:e you could be pregnant?

Have you been In jail or prison' Or parole?

Have you been di.agnosed with a psychiatrJc illness, emotional cbsorden.: or PTSD?

Do you hrJVe tattoos or body piercings?

Please Jndicate if you have ever been dJagnosed with the following;

Bladder or kJdney Infections

High Cholesterol

Hepatitis

1801 N,W. 9th Avenue

Mi.a.mi. FL 33136

Colonoscopy:

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www.MiamLTran�plant.arg

DNo 0 Yes Date:

Date[s)

Diagnosls

Professional or Homemade

Hospitalizations, If any,

Office: 305-355-SOJO

p.,., 305-355-5358

Miami Transplant

Institt1te

PosJtive TB test [Tuberculos1s)

Blood in bowel movement

Family HX ofLupus

LJHealth

ONo OYes

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AddltlonalNotes: ---------------------------------------

Return this form and all other requested items via fax 1D 305-355-5368. For additional information, call the referral office

at 305-35 5-lMTI (1684) or email MTIReferral@jhsmiami.org

1801 N,W. 9tb Avenue Miami, FL 33136

www.MiamiTransplant.org

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Office 305 355-5000

fax: 305-355-5368