Kidney-Transplant-Form

Referring Physician

Physician Contact No.

Physician Email ID

Specialty
Nephrologist
Primary care physician

Patient Demographic Information:

Patient Name:

Patient Contact No.:

Date Of Birth:

City:

Country:

Area:

Province:

Diagnosis:

Current Weight (kg):

Current Height (cm):

eGFR:

eGFR Done Date:

Patient On Dialysis
Yes
No

If yes, Dialysis type
Peritoneal Dialysis
Hemodialysis

Mention Serum Creatinine

Serum Creatinine Done Date

Patient Has Access Problems:
Yes
No

Dialysis Center

Dialysis Center Contact No.

Initial Dialysis Start Date

Dialysis Access:

Dialysis Treatment Frequency

Patient Has A Living Donor:
Yes
No

If Yes, Relationship:

Hepatitis B Status

Hepatitis B Vaccination Date

Hepatitis C Status

Cause Of Renal Failure:

Current Medication List

Comorbid And Associated Medical/Surgical Conditions

Important Past History And Assessments

Cancer (Date and Type):

Oncologist:

Cardiovascular Disease:

Cardiologist:

Pulmonary Disease

Pulmonologist:

HIV Status:

Surgical History:

Psychiatric History:

Others:

Previous Transplant:
Yes
No

Cause of Previous Transplant Failure:

Attach relevant document (recent chest x-rays, ECG,labs, discharge summary from most recent hospitalization, etc)

Location	Phone Number
Main Hospital Contact Center (8 am – 12 midnight)	+92 21 111 911 911
Main Hospital - Clinic and Radiology Appointments (8 am – 12 midnight)	+92 21 111 911 911
Main Campus 24/7 Emergency, Stadium Road	+92 21 3486 1090
Clifton Medical Services: Consulting Clinics and 24/7 Urgent Care	+92 21 111 911 911
Main Hospital Clinical Laboratory	+92 21 111 911 911
Main Hospital Blood Bank	+92 21 3486 1558
Main Hospital Drug and Poison Information	+92 21 3486 1504 +92 21 3486 1506
Main Hospital Vaccination Services	+92 21 3486 1573 +92 21 3486 1495
Patient Welfare Department	+92 21 3486 9583 +92 21 3486 9584 +92 21 3486 9585
The Aga Khan Maternal and Child Care Centre (AKMCCC), Hyderabad	+92 22 430 0777 - 8301
Aga Khan Hospital for Women Garden	+92 21 3616 7400 - 7500
The Aga Khan Hospital for Women Karimabad	+92 21 3616 7600
The Aga Khan Hospital for Women and Children, Kharadar	+92 21 3616 7800
Main Hospital New Private Wing Main Reception	+92 21 3486 8040 +92 21 3486 8041
Main Hospital New Private Wing Patient Admission and Billing Office	+92 21 3486 8026 +92 21 3486 8027
Main Hospital New Private Wing Concierge Services	+92 21 3486 8025
Patient Referral Services (9 am to 11 pm)	+92 21 3486 3100

​Kidney Transplant Referal Form

Patient Demographic Information:

Comorbid And Associated Medical/Surgical Conditions

Kidney Transplant Referal Form