Transplant Adherence Program

I give my permission to be contacted by the Transplant Adherence Program to receive further information and support tools or to provide feedback on the program.

(Note: Your program registration cannot be completed without this permission).

First Name *

Last Name *

Sex *

Age Group *

Email Address *

Confirm Email Address *

Username *

Password *

Confirm Password *

Mailing Address *

City *

Province *

Postal Code *

Home Phone *

Mobile Phone

Yes, I would be interested in subscribing to SMS text messages reminding me about refilling my prescription or next clinic appointment if the service were available.

I am: *

A Kidney Transplant Recipient
A Caregiver
A Health Care Professional

Title:

Specialization:

(skip to Program Involvement)

Please indicate whether this applies to you or the kidney recipient you are
caring for:

Primary Immunosuppressant Prescribed: Advagraf
Prograf
Neoral
Other:
Do not wish to respond

Transplant Date:

This is my first transplant

How did your hear about the Transplant Adherence Program?

My caregiver, or the kidney recipient I am caring for, is a member of the Transplant Adherence Program.

I am a member of the Transplant Companions Program, an interactive education program for pre-transplant kidney patients.

If checked, please indicate the transplant centre where you attended the Transplant Companion workshop:

Yes! I would like to receive a free Transplant Adherence Program alarm pill box to help organize and remind me when to take my once-daily or twice-daily immunosuppressive medications.

I have read, understand and agree to the Terms of Use and Privacy Statements of the Transplant Adherence Program.

Personal Information

Transplant Information

Program Involvement