Physician Referral Checklist
To refer a patient to the Johns Hopkins Comprehensive Transplant Center, please complete the appropriate form below and return to us.
For kidney or pancreas transplant, please call 410-955-5045 and press 1.
In general, we require the following information:
Physician Information
- Name
- Address
- Phone
- Fax
Patient Information
General Information
- Name
- Date of Birth
- Address
- Phone
- Social Security Number
- Insurance Information
Patient’s Medical History and Records
- Medical History
- Surgeries / Procedures
- Devices, including type and settings
Patient Medications
- Type(s)
- Dosages
- Allergies
Diagnostic Test Results
- Current chest X-ray report
- PPD (tuberculosis skin test)
- Mammogram
- Colonoscopy
- Stress test and other cardiac information
- Other information as available
Additional Test for Lung Transplantation
- Current chest X-ray report and films
- Current chest CT scan
- Complete Pulmonary Function Testing