~ Welcome to Renewal ~

Information provided will be kept strictly confidential.
(If you have any questions please do not hesitate to call us at 718-431-9831).

“G-d runs the world, and when presented with a mitzvah, an opportunity to save someone’s life, one should grab it. For it may not come again. To hold back and live in a world of “What if…?” could cost lives. How can I not give away my kidney, just because it’s for someone I don’t know? Somebody knows them. They are someone’s wife, sister, friend and daughter.”

~Lori Palatnik; a donor (North Bethesda, MD – noted Aish HaTorah Lecturer)

"There's a lot of misconceptions about kidney donation and a lot of fear. But if people take the time to get the facts, they find out the risks are very minimal. People are born with two kidneys. You only need one."

~ Michelle Winsor, a kidney transplant coordinator with Sharp Memorial Hospital

First Name :

Middle :

Last Name :

ABO (Blood Type) :

Height :

Feet

inches

Weight :

Gender :

Male

Female

Date of Birth :

Age :

Address :

Email :

City :

State :

Zip Code :

Phone :

Alternate Phone:

Work

Cell

Current Work Status:

Employed

Self-Employed

Homemaker

Unemployed

Student

Marital Status :

Single

Married

Divorced

(If you are found suitable to donate, you can expect to be off work 2-3 weeks)

Is there any particular person you would like to donate your kidney to?

Yes

If yes, please specify:

Please answer the following few questions

Are you currently taking prescription or non-prescription (over the counter) drugs?

Yes

If yes, please list :

Do you have a history of hypertension (high blood pressure)?

Yes

Have you ever had any episodes of chest pain or shortness of breath?

Yes

If yes, please explain :

Do you have a history of diabetes?

Yes

Do you have a history of :

kidney stones

Yes

renal disease

Yes

If yes, how long ago? :

Have you ever had a blood transfusion?

Yes

7.	Is there anything else you think we should know about your health? :

If you wish to receive our Donor Guide, please check this box

Thank you to all past and future donors.
Without them, transplantation is just a wish.

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