This form is for patients with end-stage liver disease and referring providers who wish to start the process of patient evaluation toward transplant. A person who has received consent and authorization on behalf of a patient toward the patient’s evaluation may also complete the form as patient designee. A representative from Yale New Haven Transplantation Center will contact the patient within two business days.
This form is not for medical emergencies. If you are currently experiencing a medical emergency, please contact your current healthcare provider, dial 911 or go to your nearest emergency department.
