Kidney Transplant Referral Form
Baystate Transplant Program Exclusion Criteria
Please refrain from referring patients with any active exclusion criteria:
- Open wounds
- Active cigarette smoking
- Active cancer
- Incarceration
- Experiencing homelessness
- BMI > 45
Contact our program with any questions.
Refer a Patient
Complete the form below to refer a patient to the Adult Kidney Transplant Program at Baystate Medical Center. This form may be completed by a referring physician, a patient, or someone a patient has authorized to complete the form.
Please note that this form is not intended for medical emergencies. Do not use this form for appointments needed within 72 hours.
Please attach the following documentation using the file upload at the bottom of this form or fax copies to 413-795-8514:
- GFR <20/most recent labs
- 2728 Form (if applicable)
- H & P or most recent office note
- Insurance information
Someone from the Kidney Transplant Program will contact you to schedule an appointment.
Patient Consent: To refer a patient or complete the form on a patient's behalf, please ensure that you have the patient's consent.
Start Your Referral:
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