Coronavirus (COVID-19)
* = required field
Please note the following:
This form is to be completed by a referring physician. A representative from the Comprehensive Liver Center will contact you within one business day.
After submitting this form, please make sure to fax the following information to the Transplant Program office at 860-972-9972
– Insurance card(s) – front and back
– Medical notes (H&P)
– Diagnostic test results (i.e. CT, MRI, U/S of ABD, etc.)
Loading...