Transplant Living Donor Application
Welcome to the Ascension St. John Transplant Center. Thank you for your willingness to explore being a living kidney donor. It is truly a life-saving gift. We are so excited to work with you. Please take your time answering all of the questions below to the best of your ability. This will help our team give you the best possible care and streamline your evaluation process. This paperwork is required to be completed in order to be considered for living donation and to begin the evaluation process. Once we have received your response, the providers will review this form, and you will be contacted as soon as possible. If you have any questions about how to fill out this paperwork, please call 918-744-3653 or email Holly.Wall@ascension.org. Thank you again!
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Email Address *
Legal First and Last Name *
Preferred Name
Date of Birth *
Donors must be between 21 and 65 years old.
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Sex at Birth *
Current Gender Identity *
Race *
Ethnicity *
Citizenship *
Height *
Weight in pounds *
Donors must have a BMI < 35. To calculate your BMI, go to https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm.
Mailing Address *
City, State, Zip Code *
Please note that evaluation for living donation does require travel to the St. John Transplant Center in Tulsa, OK.
Cell Phone Number *
Additional Phone Numbers
Emergency Contact (Name, relationship, and phone number) *
Marital Status *
Preferred Language *
Highest Education *
Do you have Health Insurance? *
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