EMERGENCY NEEDS FOR TRANSPLANT PATIENTS - Liver/IntestineNameAddress:

Home Phone:Work Phone:Cell Phone:Insurance InformationInsurance Information

Medicare NumberOther InsuranceGroup Policy Contact Number

Medical Information

Cause of Liver FailureCause of Intestinal FailureOther Medical Conditions

Previous Surgeries or Complications

Type of Transplant Ο Liver Ο Liver/Kidney Ο Small Bowel Ο Liver/Small Bowel/Pancreas Ο Other:Transplant Date

Allergies

Transplant Center InformationYour Transplant Center:The Nebraska Medical Center/Univerity of Nebraska Medical Center

983285 Nebraska Medical CenterOmaha, Nebraska 68198-3285Phone: 800-401-4444; 402-559-5000Fax: 402-552-3030, 402-552-3619, 402-552-3052Transplant Surgeons:

Pediatric Gastroenterologists: Dr. Ruben Quiros, Dr. Benjamin Infantino, Dr. Pablo Palomo Website: www.nebraskamed.com

Physician InformationYour Primary Care Physician's Name, Address and Phone:

Your Hepatologist's Name, Address and Phone:

Medical Support Contact InformationYour Pharmacy's Name, Address and Phone:

Your Laboratory's Name, Address and Phone:

Your Local Hospital or Emergency Room's Name, Address and Phone:

Emergency Contact InformationYour Emergency Contact Person's Name, Address and Phone:

Medication List:

Name of Medication Dose Frequency

Dr. Wendy Grant, Dr. Alan Langnas, Dr. David Mercer, Dr. Luciano Vargas Transplant Hepatologists: Dr. David Schafer, Dr. Timothy McCashland, Dr. Fedja Rochling Dr. Marco Olivera-Martinez