Registration

Transplant Directory Consent Form

I am requesting to be listed in the liver/kidney/pancreas support group directory. This directory includes information concerning my name, permanent, temporary and e-mail addresses, telephone numbers, date and type of transplant. Information may also include my caregiver's name, address, phone number and e-mail address. I am aware that this information is shared with other transplant patients, patients listed for transplant, and their caregivers.

I am aware that the directory is a communication tool to promote an exchange of information and support as requested. This directory is produced and maintained by members of the group. I am aware that this information is to be used by group members only.

If at any time I wish to have my name removed from the transplant directory, I may contact the transplant social worker and submit the request in writing to do so.

Patient Information
First Name:	Last Name:
Permanent Address:
Permanent Phone:	Cell Phone: (format 999-999-9999)
E-mail Address:
Temporary Address:
Temporary Phone: (format 999-999-9999)
Type of Transplant:	Date of Transplant: (format mm/dd/yyyy)
Status:
Caregiver Information
Caregiver's First Name:	Caregiver's Last Name:
Permanent Address:
Permanent Phone: (format 999-999-9999)	Cell Phone: (format 999-999-9999)
E-mail Address:

By checking this box I confirm that I wish to include the above information in the Second Chance Jax private Transplant Directory
Yes No include this information on the Second Chance Jax web site (available for public view)