Transplant Referral Form

To request an initial consultation with Memorial Health's Transplant Services, please fill out the online form below, or print a transplant patient referral form, complete and email to We accept physician referrals and self-referrals.  Please complete form to the best of your ability, not all fields are required. 

Patient Info

Personal Information

Patient Medical Information

Patient Demographics


If you have any of the following documentation, please upload with your request below. If you do not have these documents to attach to this online request for consultation, please fax them to 217-788-4606. Please make sure that all documents have the patient's name and DOB on them. If this is a self-referral, we will contact your physician to secure these necessary documents prior to consultation.

I request to be scheduled for an appointment for transplant evaluation at Memorial Health. I hereby authorize Memorial Health Transplant Services to access by clinical and financial records limited to information pertaining to my care as a transplant patient.