Formulier voor transplantatie buitenland

1. Centre where case was identified

Centre name

City name

2. Date of transplantation

Date of transplantation

3. Organ transplanted

Choose as many as apply

Organ transplanted

Kidney Liver Lung Heart Pancreas Intestine

4. Country where transplantation took place

Fill in the country where transplantation took place

5. City and hospital where transplantation took place

City where transplantation took place

Hospital where transplantation took place

6. Referral of the recipient by your centre or a centre in your country for transplantation abroad

Specify if the patient was referred by your centre or a centre in your country for transplantation in another country.

Referral should be understood as the establishment of a direct contact between the centre of origin and the centre where the transplantation procedure would take place in order to ensure transfer of medical records and continuity of care.

Referral should not be understood as a simple recommendation to travel for transplantation abroad without any further engagement or contact between the centre of origin and the centre where the transplantation procedure would take place.

Specify if the patient was referred by your centre or a centre in your country for transplantation in another country.

Specify hereYesNo

6 a. Reason for referring the recipient for transplantation abroad

Choose as many as apply

Reason for referring the recipient for transplantation abroad

Established official bilateral agreement with the government of the country where the transplantation procedure would take place Genetically or emotionally related donor living in the country of destination Double citizenship of the recipient Other reason (please specify below)

7. Donor type

According to the World Health Organization classification, a living donor has one of the following relationships with the recipient:

A. Related

A1. Genetically related

• 1st degree genetically related: e.g. parent, sibling offspring
• 2nd degree genetically related, e.g. grandparent, grandchild, aunt, uncle, niece, nephew
• Other than 1st or 2nd degree genetically related, e.g. cousin

A2. Emotionally related, e.g. spouse, (if not genetically related, in-law, adopted, friend).

B. Unrelated: not genetically or emotionally related

Select which donor type

Deceased Living – genetically related 1st degree Living – genetically related 2nd degree Living – genetically related other than 1st or 2nd degree Living – emotionally related Living – unrelated Not available

8. Any other comment

Specify here