BREEZE
Welcome to the BREEZE TRANSPLANTTM online health history questionnaire.
Thank you for your interest in becoming a living kidney donor. We are committed to looking after your health and safety throughout the donation process.
You can start the process by filling out the form below and answering the subsequent basic questions about whom you wish to donate to and your state of health. Submission of the form does not imply any commitment or obligation on your part. You can stop the process at any time.
This survey will take approximately 15-20 minutes to complete. You must complete the survey in a single session, and we recommend you use a desktop or laptop computer for best results.
Your Name
You must enter your full name to certify your legal consent.
.
First
txtFirstName textfield
.
Middle (if applicable)
txtMiddleName textfield
You must enter your full name to certify your legal consent.
.
Last
txtLastName textfield
You must enter your date of birth and you must be between the ages of 18 and 70 to proceed.
Your Birth Date
dob textfield
You must select your gender to proceed.
Your Gender
sexFemale radiobutton
You must select your height to proceed.
Your Height
(feet) (inches)
heightInches listchoice
You must enter your weight to proceed, and your weight must be greater or equal to 60 pounds and below 700 pounds.
Your Weight
(lbs)
weight textfield
Please provide your primary phone number and type.
Primary Phone
phonebesttype listchoice
Your email address appears to be incorrect.
Your email address (optional)
txtEmail textfield
You must select a donor type to proceed.
Donor Type
donortype.namedrecip radiobutton
.
donortype.altruist radiobutton
You must enter the recipient's first name.
Recipient's First Name
txtRecipientName textfield
You must enter the recipient's last name.
Recipient's Last Name
txtRecipientLastName textfield
Recipient's Birth Date
dobRecipient textfield
You must indicate your agreement with the terms of use to proceed.
Terms of Use and wish to proceed
chk itemchoice
.
nextButton imagechoice
The information collected in this survey is strictly confidential and protected by Federal Law. Results are transmitted back to your health care providers.

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Please answer the following questions before continuing: