Free appointment schedule template 36
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Appointment Schedule
Reimbursement Program for Living Donors (RPLD)
This form must be completed by the transplant centre in block letters.

Family name of applicant :

Given name of applicant :

Date of birth of applicant :

yyyy

Health insurance number of applicant :

mm

dd

Name of transplant centre :

Kidney

Liver
Légend

Purpose of the visit - Please refer to the legend
(If "other", please specify)
Date (yyyy-mm-dd)

Code

Comments

Code Description
L

Lab

I

Imaging

SC Surgery consultation
EX

More in-depth examination

T

Tissue typing

T

Teaching

H

Pre-surgical hospitalization

MC Medical consultation
PC Psychological consultation
O

Other

Confirmation of eligibility under the Reimbursement Program for Living Donors
-

Date of procurement surgery: :
yyyy

Date of hospital discharge :

mm

yyyy

mm

Not applicable

Pending

Not applicable

Pending

dd

dd

Is this donor signed up to the Living Donor Paired Exchange Registry ?

Yes

If so, please name the participating ho