SKIP TO CONTENT
Help
|
Urgent Care
PATIENT PORTAL
PAY BILL
CAREERS
CONTACT
Toggle navigation
Doctors
Services
Locations
Resources
Patients
Patient Portal
Pay Bill
Careers
Contact
INTEGRIS Health Nazih Zuhdi Transplant Institute
INTEGRIS Health Nazih Zuhdi Transplant Institute
INTEGRIS Health Nazih Zuhdi Transplant Institute
Explore Services
Advanced Disease Management
Clinical Trials
Heart Transplant
Kidney and Pancreas Transplant
Procedure
Living Donor (Kidney)
Criteria List
Patient Orientation Videos
Patient Resources
Kidney and Pancreas Self Referral Form
Kidney Corner Podcast
Liver Transplant
Lung Transplant
Transplant Outreach Locations
Find a Doctor
Organ Donation
COVID-19 Vaccine
Patients and Visitors
Learn About Us
Menu
INTEGRIS Health Nazih Zuhdi Transplant Institute
Explore Services
Advanced Disease Management
Advanced Endoscopy and Hepatopancreatobiliary Surgery
Heart and Lung Programs
Kidney and Pancreas Programs
Liver Program
Hepatitis C Clinic
Pulmonary Hypertension
Transplant Referral Forms
Clinical Trials
Heart Transplant
Procedure
Criteria List
Patient Orientation Videos
Kidney and Pancreas Transplant
Procedure
Living Donor (Kidney)
Criteria List
Patient Orientation Videos
Patient Resources
Kidney and Pancreas Self Referral Form
Kidney Corner Podcast
Liver Transplant
Criteria List
Liver Transplant Procedure
Patient Orientation Videos
Lung Transplant
Criteria List
Procedure
Patient Orientation Videos
Transplant Outreach Locations
Find a Doctor
Organ Donation
COVID-19 Vaccine
Patients and Visitors
Contact Us
Directions and Parking
Learn About Us
About Nazih Zuhdi
Phone
405-949-3349
Address
3300 NW Expressway
Oklahoma City, OK 73112
GET DIRECTIONS
Kidney and Pancreas Self Referral Form
* Required fields
* First Name
* Last Name
* Email
* Home Phone
* Cell Phone
Work Phone
* Address 1
Address 2
* City/Town
* State
* Zip Code
INTEGRIS Health may contact me
* Date of Referral
* SSN
* Date of Birth
* Marital Status
Single
Married
Divorced
Widow
* Gender
Female
Male
* Insurance Company Name
* Insurance Subscriber Number
* Insurance Group Number
* Have there been any non-compliance concerns in the last 3 months?
Yes
No
If yes, please explain
* Is this referral for:
Kidney only
Pancreas only
Kidney and Pancreas
* Referring Nephrologist
Address
City
State
ZIP
Phone
Fax
* Cause of ESRD
* Does patient have Indian Health Services?
Yes
No
* Is the patient on dialysis?
Yes
No
If yes, provide date started
Dialysis Center
Address
City
State
ZIP
Phone
Fax
Type
Hemodialysis
PD
Schedule
If patient is on Dialysis, Please provide: Psychosocial History
Check patient's special needs
Illiterate
Deaf
Blindness
Does not speak English
Upon completion of this form, please fax the following documents to 405-815-6404: CMS 2728, drivers license, social security card, insurance card(s), history and physical from your nephrologist.
