1144 E. Home Road, Suite B • Springfield, Ohio 45503-2797
Phone (614) 504-5705 • Fax (614) 504-5707
www.osotc.org
POST-TRANSPLANT FORM
To be completed for all transplant recipients at time of initial discharge from transplant hospitalization,
and/or upon death, or in the event of a pancreatic rejection episode.
Initial Discharge
Death
Center:
Pancreas Rejection
Completed by:
Patient Information:
Patient Name:
Organ:
Birth Date:
MRN#:
Primary Insurance:
State of Residence:
Private/Commercial
Medicaid
Medicare
None
Other
Secondary Insurance: Private/Commercial
Medicaid
Medicare
None
Other
Transplant Information:
Primary Diagnosis:
Date of Transplant:
Secondary Diagnosis:
Date of Admission:
Date of Discharge:
Prior Transplant Date(s):
Lost to Follow-up:
Death:
Cause of Death:
Date of Death:
Donor Information:
UNOS Donor ID#
Ohio Donor:
Yes
No
Race:
ABO:
Sex:
Weight (lbs):
Height (in):
Age:
For Pancreas Only:
Full Functioning Pancreas
Date of Total Pancreas Failure:
Partial Functioning Pancreas
Non-Functional Pancreas
Date of Pancreas Graft Removal:
(v15.0528)