PATIENTS SEEKING DONORS

Start by telling us more about yourself. You will have an opportunity to approve your profile before it goes live.

Need help?

Please contact alexandraf@transplantambassadors.ca and we will assign a transplant ambassador representative to help you complete your online profile.

* Fields are required

First Name *

Last Name

City *

Province *

** Rather than use your personal email, TAP will provide you will a temporary email address on our secure server that can be used and used on your profile for potential donors to reach out to you.

Personal Email Address (where TAP can reach you) ** *

Do you want your personal email to appear on your profile ? * *

• Yes
• No

Or do you want TAP to assign you a temporary email to appear on your profile ? * *

• Yes
• No

Personal Phone Number (for TAP to reach you) *

Do you want your phone number to appear on your profile? * *

• Yes
• No

When is the best time to contact you?

• Morning
• Afternoon
• Evening

Social Media Links

Facebook Page URL

Instagram Page URL

Twitter Page URL

Linked In Page URL

Do you want your social media links to appear on your profile? *

• Yes
• No

Current kidney function description

Age

Blood Type *

Reason/details of kidney failure if known

What is your transplant status? * *

• Active
• Successfully Transplanted

Are you willing to share your story with the media if they ask? * *

• Yes
• No

Has anyone in your family / networks offered to be a living donor? *

• Yes
• No

If a person(s) has offered to be your donor, please click all that apply *

• Is not a match and not interested in paired donor exchange
• Is not able to be a donor because of other health conditions
• Is concerned or tentative about being a donor
• Is working on making lifestyle changes (eg. Losing weight) to be considered
• Is someone I don’t want to accept a kidney from
• Other

Is it someone you don’t want to accept a kidney from, why not? (TAP info only)

Thank you for taking the time to fill out our patient profile questionnaire.

Will you need assistance setting up your online profile page? *

• Yes
• No

Upload Photo *

Attach a photo of yourself that is not already used on any social media platforms or, a high resolution image you want to use to represent yourself.

Personal Notes About You To Appear On Your Online Profile *

Limit 1,500 characters

Confidential Information you wish to share with TAP

Unlimited characters

Please provide the name and/or contact information for the living donor coordinator at the transplant hospital you are being worked up for transplant.

Where did you find out about our 'Patients Seeking Donors' service?

Upload Video URL

Video should be no longer than 2 minutes

The Transplant Ambassador Program is not responsible for the result of any actions or interactions between any persons, including potential recipients and potential donors, who have made connections using the information on this website.

*

• I confirm that I am a kidney patient or parent of a kidney patient and am over the age of 18.

*

• I confirm that I am covered by one of the provincial healthcare systems in Canada.

*

• I am agreeing to have my profile posted on this website and I understand that it is a public website and, therefore once it is live, my profile can be viewed by anyone at anytime, and that the Transplant Ambassador Program is not responsible for the result of actions or interactions between any persons, including potential recipients and potential donors who have made connections with me using the information I have provided. I have the right to ask that my profile be removed from the website at any point and that, upon my request, my profile will be removed within 48 hours.

Email for Donor to contact Patient (TAP only fill in)

Display Email?

YesNo

Validate Email