Kidney Transplant Online Referral Form

* = required field

Please note the following:

This form is to be completed by a referring physician, patient, or a person the patient has authorized to complete this form. Please do not complete this form if you do not have the patient's consent.

This form is not designed to respond to medical emergencies. If you are currently experiencing a medical emergency, please contact your current health care provider, dial 911 or go to your nearest emergency room.

A representative from the Kidney Transplant Program will contact you within 3-5 business days.

Please fax the 2728 or most recent Nephrology Note to 860.545.4366.

(Please note: Appointments are available on select days at the Bridgeport clinic.)

Kidney Transplant Program