Erase the Wait Mentee Referral

If you are a patient or have a patient interested in participating in our Erase the Wait Living Kidney Mentorship program, please fill out the form below. Please know that they will receive contact from us within 2 weeks time. If you have any issues with the form, please contact us at livingdonation@donatelifenw.org or call our office at 503-494-7888.

Patient information

First Name

Last Name

Phone Number

Preferred Contact Method

Phone

Does the patient need translation services?*

No, the patient speaks English

Yes, the patient will need Spanish translation

Yes, the patient will need translation in another language (please note in comment section below)

Transplant Center*

OHSU

Legacy

How long has the patient been on the waitlist?

Please describe any relevant medical information regarding the patient's need for a transplant.

What steps has the patient taken to find a living donor (if any)?

Any other comments or questions?

If this form was filled out by someone other than the patient, please list your name and contact info here.

Stories of Hope

— Hayley Resk

Erase the Wait Mentee Referral