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1 forms found in the DOM

POST /Home/Submit

<form class="form" id="intakeForm" enctype="multipart/form-data" action="/Home/Submit" method="post">
  <div class="panels">
    <div class="panels__item">
      <section class="panel">
        <header class="panel__header">
          <div class="panel__header-content">
            <h2 class="panel__heading">Steps to Create your Story</h2>
          </div>
        </header>
        <div class="panel__body">
          <div class="richtext">
            <ul>
              <li>Enter patient information</li>
              <li>Write your story <em>(TIP - copy and save your story outside the online submission form)</em></li>
              <li>Upload your photos</li>
              <li>Submit your story</li>
              <li>Receive email with approval</li>
              <li>Share your story through social media or email</li>
            </ul>
          </div>
        </div>
      </section>
    </div>
    <div class="panels__item">
      <section class="panel">
        <header class="panel__header">
          <div class="panel__header-content">
            <h2 class="panel__heading">Patient Information</h2>
            <div class="richtext">
              <p>Enter in your contact information and transplant type below.</p>
            </div>
          </div>
        </header>
        <div class="panel__body">
          <div class="panel__section">
            <div class="form-field-group">
              <div class="form-field">
                <label for="first-name">First Name</label><input type="text" class="form-control validRequired" id="first-name" name="FirstName" value="">
              </div>
              <div class="form-field">
                <label for="last-name">Last Name</label><input type="text" class="form-control validRequired" id="last-name" name="LastName" value="">
              </div>
              <div class="form-field">
                <label for="email">Email Address</label><input type="email" class="form-control validRequired validEmail" id="email" name="EmailAddress" value="">
              </div>
              <div class="form-field form-field--has-value">
                <label for="primary-location" id="primary-location_enhance_lbl">Transplant Location</label>
                <div class="select-enhance" id="primary-location_enhance_wrap"><select class="form-control validSelected" id="primary-location" data-val="true" data-val-required="The PrimaryLocationId field is required." name="PrimaryLocationId"
                    tabindex="-1" aria-hidden="true">
                    <option value="-1" disabled="" selected="">Transplant Program Location</option>
                    <option value="1">Dallas, TX</option>
                    <option value="2">Fort Worth, TX</option>
                  </select><input type="text" class="select-enhance__enable-text" role="combobox" aria-controls="primary-location_enhance_listbox" aria-labelledby="primary-location_enhance_lbl" aria-autocomplete="list" aria-expanded="false"
                    id="primary-location_enhance_input" aria-activedescendant="primary-location_enhance0">
                  <div class="select-enhance__list" role="listbox" id="primary-location_enhance_listbox" aria-label="Transplant Location">
                    <div tabindex="0" role="option" id="primary-location_enhance0" data-value="-1" aria-selected="true" disabled="disabled" class="select-enhance__list-btn">Transplant Program Location</div>
                    <div tabindex="0" role="option" id="primary-location_enhance1" data-value="1" aria-selected="false" class="select-enhance__list-btn">Dallas, TX</div>
                    <div tabindex="0" role="option" id="primary-location_enhance2" data-value="2" aria-selected="false" class="select-enhance__list-btn">Fort Worth, TX</div>
                  </div>
                </div>
              </div>
              <div class="form-field"><label for="patient-coordinator">Patient Transplant Coordinator Name (not required).</label><input type="text" class="form-control" id="patient-coordinator" name="PatientCoordinator" value=""></div>
              <div class="form-field form-field--has-value">
                <label for="transplant-type" id="transplant-type_enhance_lbl">Transplant Type</label>
                <div class="select-enhance" id="transplant-type_enhance_wrap"><select class="form-control validSelected" id="transplant-type" data-val="true" data-val-required="The TransplantType field is required." name="TransplantType"
                    tabindex="-1" aria-hidden="true">
                    <option value="-1" disabled="" selected="">Select Your Transplant Type</option>
                    <option value="1">Kidney</option>
                    <option value="2">Liver</option>
                  </select><input type="text" class="select-enhance__enable-text" role="combobox" aria-controls="transplant-type_enhance_listbox" aria-labelledby="transplant-type_enhance_lbl" aria-autocomplete="list" aria-expanded="false"
                    id="transplant-type_enhance_input" aria-activedescendant="transplant-type_enhance0">
                  <div class="select-enhance__list" role="listbox" id="transplant-type_enhance_listbox" aria-label="Transplant Type">
                    <div tabindex="0" role="option" id="transplant-type_enhance0" data-value="-1" aria-selected="true" disabled="disabled" class="select-enhance__list-btn">Select Your Transplant Type</div>
                    <div tabindex="0" role="option" id="transplant-type_enhance1" data-value="1" aria-selected="false" class="select-enhance__list-btn">Kidney</div>
                    <div tabindex="0" role="option" id="transplant-type_enhance2" data-value="2" aria-selected="false" class="select-enhance__list-btn">Liver</div>
                  </div>
                </div>
              </div>
            </div>
          </div>
        </div>
      </section>
    </div>
    <div class="panels__item">
      <section class="panel">
        <header class="panel__header">
          <div class="panel__header-content">
            <h2 class="panel__heading">Upload Photo #1</h2>
            <div class="richtext">
              <p>Upload an image of yourself here. The image needs to be in a square orientation since the framing of the photo will center automatically. Make sure the subject matter is in the center of the image.</p>
            </div>
          </div>
        </header>
        <div class="panel__body">
          <div class="panel__section">
            <div class="form-file-field form-file-field--narrow">
              <input type="hidden" data-val="true" data-val-required="The ImageOneId field is required." id="ImageOneId" name="ImageOneId" value="0">
              <label for="imageOne">Upload Photo #1</label>
              <input type="file" class="form-file-field__input" id="imageOne" accept="image/*" aria-describedby="image-1-btn" name="ImageOne">
              <div class="form-file-field__btn" id="image-1-btn">
                <div class="form-file-field__btn-inner" style="">
                  <span class="icon icon-image-upload" aria-hidden="true"></span>
                  <span class="form-file-field__heading">Drop a file here or click to upload</span>
                  <span class="form-file-field__subheading">Maximum upload size: 10MB</span>
                </div>
              </div>
            </div>
          </div>
        </div>
      </section>
    </div>
    <div class="panels__item">
      <section class="panel">
        <header class="panel__header">
          <div class="panel__header-content">
            <h2 class="panel__heading">Write Your Story</h2>
            <div class="richtext">
              <p>It can be hard to write about yourself, but it’s important for people to relate to your story. Be honest about what you’re going through and how people can help. View a sample story:
                <a href="/assets/img/SampleStory_English_Kidney.pdf" target="_blank">Kidney</a> | <a href="/assets/img/SampleStory_English_Liver.pdf" target="_blank">Liver</a>
              </p>
              <p>Describe who you are and why you need a transplant. You might include the following:</p>
              <ul>
                <li>Your name</li>
                <li>Your family (spouse, children, etc.)</li>
                <li>What you do (job, career, parent, homemaker, etc.)</li>
                <li>Your journey to kidney or liver failure</li>
                <li>How your diagnosis impacts your life (working, family, dialysis, energy, sickness, etc.)</li>
                <li>What type of transplant you need (kidney, liver)</li>
                <li>How long you have been waiting, or how long you will have to wait without a living donor</li>
                <li>Share why you hope for a living donor instead of waiting on the transplant list</li>
              </ul>
            </div>
          </div>
        </header>
        <div class="panel__body">
          <div class="panel__section">
            <div class="form-field"><label for="patient-story">Your Story</label><textarea class="form-control validRequired" id="patient-story" maxlength="2000" name="YourStory"></textarea>
              <div class="char-counter">2000</div>
            </div>
          </div>
        </div>
      </section>
    </div>
    <div class="panels__item">
      <section class="panel">
        <header class="panel__header">
          <div class="panel__header-content">
            <h2 class="panel__heading">How a Transplant Will Help You</h2>
            <div class="richtext">
              <p>Share how having a transplant will help you and have a positive impact on your life:</p>
              <ul>
                <li>Ways that you will feel better</li>
                <li>What you will be able to do that you cannot do now </li>
                <li>What you look forward to doing after transplant </li>
              </ul>
            </div>
          </div>
        </header>
        <div class="panel__body">
          <div class="panel__section">
            <div class="form-field"><label for="transplant-status">How a Transplant Will Help You</label><textarea class="form-control validRequired" id="transplant-status" maxlength="2000" name="TransplantReason"></textarea>
              <div class="char-counter">2000</div>
            </div>
          </div>
        </div>
      </section>
    </div>
    <div class="panels__item">
      <section class="panel">
        <header class="panel__header">
          <div class="panel__header-content">
            <h2 class="panel__heading">Upload Photo #2</h2>
            <div class="richtext">
              <p>Upload another image here. It could be another photo of you, your family, friends, etc. The image should be oriented vertically. Make sure the subject matter is in the center of the image.</p>
            </div>
          </div>
        </header>
        <div class="panel__body">
          <div class="panel__section">
            <div class="form-file-field">
              <input type="hidden" data-val="true" data-val-required="The ImageTwoId field is required." id="ImageTwoId" name="ImageTwoId" value="0">
              <label for="imageTwo">Upload Photo #2</label>
              <input type="file" class="form-file-field__input" id="imageTwo" accept="image/*" aria-describedby="image-2-btn" name="ImageTwo">
              <div class="form-file-field__btn" id="image-2-btn">
                <div class="form-file-field__btn-inner" style="">
                  <span class="icon icon-image-upload" aria-hidden="true"></span>
                  <span class="form-file-field__heading">Drop a file here or click to upload</span>
                  <span class="form-file-field__subheading">Maximum upload size: 10MB</span>
                </div>
              </div>
            </div>
          </div>
        </div>
      </section>
    </div>
    <div class="panels__item">
      <section class="panel">
        <header class="panel__header">
          <div class="panel__header-content">
            <h2 class="panel__heading">Approval Process</h2>
            <div class="richtext">
              <ul>
                <li>Sign the authorization form via DocuSign to submit your profile.</li>
                <li>A member of our team will review your profile and notify you of approval or request to modify it within three (3) business days via your provided email.</li>
                <li>Submissions with curse words, vulgarities or mentions of other transplant programs will be denied.</li>
                <li>If your submission is denied, you will not be able to edit your first submission. You will need to submit a new story with the requested changes.</li>
                <li>In this case, you can refer back to the copy of your story that you saved outside the online submission form to more easily make changes.</li>
              </ul>
            </div>
          </div>
        </header>
      </section>
    </div>
  </div>
  <input type="hidden" data-val="true" data-val-required="The Language field is required." id="Language" name="Language" value="English">
  <div class="form__footer">
    <div class="btn-group">
      <button type="submit" class="btn btn-outline-primary" onclick="$('#intakeForm').attr('target', '_blank');$('#IsPreview').val('True');return checkValidation('intakeForm');">Preview Profile</button>
      <button type="submit" class="btn btn-primary-teal btn-confirm" onclick="$('#intakeForm').removeAttr('target');$('#IsPreview').val('False');return checkValidation('intakeForm');" data-confirm-type="sign-submit-docusign">Sign and Submit</button>
    </div>
  </div>
  <input type="hidden" data-val="true" data-val-required="The IsPreview field is required." id="IsPreview" name="IsPreview" value="False">
  <input name="__RequestVerificationToken" type="hidden" value="CfDJ8K0DQlB-fuFPsOCWhV8y1DJNVGxk-Q5oNkZpBdZA2RVgi5J4FgnFuoE-lisYwCq0QoanOqHcWx6TDT0kA6EZSNTGo3TIZucCW8t_QVqTOUMaoe7rLRsWWuX8OQpUuezDiE3Wl5n0M3EwC9xP9btKTsM">
</form>

Text Content

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BAYLOR SCOTT & WHITE TRANSPLANT PATIENT STORIES

Create and Share Your Story

A tool to help you find a living donor

Living donor transplant can shorten your wait for a transplant and improve your
chances of success. You may not be comfortable asking people to donate, but we
have found it helpful to make people aware of your need for a donor. We
recommend that you simply share your story as it helps to make others aware of
your need.

Baylor Scott & White Health supports your transplant journey by helping you
create your story to share.



STEPS TO CREATE YOUR STORY

 * Enter patient information
 * Write your story (TIP - copy and save your story outside the online
   submission form)
 * Upload your photos
 * Submit your story
 * Receive email with approval
 * Share your story through social media or email


PATIENT INFORMATION

Enter in your contact information and transplant type below.

First Name
Last Name
Email Address
Transplant Location
Transplant Program Location Dallas, TX Fort Worth, TX
Transplant Program Location
Dallas, TX
Fort Worth, TX
Patient Transplant Coordinator Name (not required).
Transplant Type
Select Your Transplant Type Kidney Liver
Select Your Transplant Type
Kidney
Liver


UPLOAD PHOTO #1

Upload an image of yourself here. The image needs to be in a square orientation
since the framing of the photo will center automatically. Make sure the subject
matter is in the center of the image.

Upload Photo #1
Drop a file here or click to upload Maximum upload size: 10MB


WRITE YOUR STORY

It can be hard to write about yourself, but it’s important for people to relate
to your story. Be honest about what you’re going through and how people can
help. View a sample story: Kidney | Liver

Describe who you are and why you need a transplant. You might include the
following:

 * Your name
 * Your family (spouse, children, etc.)
 * What you do (job, career, parent, homemaker, etc.)
 * Your journey to kidney or liver failure
 * How your diagnosis impacts your life (working, family, dialysis, energy,
   sickness, etc.)
 * What type of transplant you need (kidney, liver)
 * How long you have been waiting, or how long you will have to wait without a
   living donor
 * Share why you hope for a living donor instead of waiting on the transplant
   list

Your Story
2000


HOW A TRANSPLANT WILL HELP YOU

Share how having a transplant will help you and have a positive impact on your
life:

 * Ways that you will feel better
 * What you will be able to do that you cannot do now
 * What you look forward to doing after transplant

How a Transplant Will Help You
2000


UPLOAD PHOTO #2

Upload another image here. It could be another photo of you, your family,
friends, etc. The image should be oriented vertically. Make sure the subject
matter is in the center of the image.

Upload Photo #2
Drop a file here or click to upload Maximum upload size: 10MB


APPROVAL PROCESS

 * Sign the authorization form via DocuSign to submit your profile.
 * A member of our team will review your profile and notify you of approval or
   request to modify it within three (3) business days via your provided email.
 * Submissions with curse words, vulgarities or mentions of other transplant
   programs will be denied.
 * If your submission is denied, you will not be able to edit your first
   submission. You will need to submit a new story with the requested changes.
 * In this case, you can refer back to the copy of your story that you saved
   outside the online submission form to more easily make changes.

Preview Profile Sign and Submit


CONFIRM REDIRECTION

You are being redirected to DocuSign to complete an authorization form in order
to submit your story.

Cancel Submit

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 * Terms of Use
 * Notice of Non-Discrimination

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301 N. Washington Ave., Dallas, TX 75246 | 866.454.1703