Kidney Transplant Recipient | UPH Des Moines

UnityPoint Clinic - Express

180 Jordan Creek Parkway, Suite 120
West Des Moines, Iowa 50266

Closed Patients
Waiting Now

UnityPoint Clinic Adult Respiratory Illness

2103 Ingersoll Ave., Ste. 2
Des Moines, Iowa 50312

Closed Patients
Waiting Now

UnityPoint Clinic Urgent Care - Altoona

2720 8th St. SW
Altoona, Iowa 50009

Closed Patients
Waiting Now

Urgent Care - Ankeny

3625 N. Ankeny Blvd.
Suite E
Ankeny, Iowa 50023

Closed Patients
Waiting Now

Urgent Care - Lakeview

6000 University Avenue
Suite 101
West Des Moines, Iowa 50266

Closed Patients
Waiting Now

Urgent Care - Merle Hay

4020 Merle Hay Road
Suite 100
Des Moines, Iowa 50310

Closed Patients
Waiting Now

Urgent Care - Southglen

6520 SE 14th St.
Des Moines, Iowa 50320

Closed Patients
Waiting Now

Urgent Care - Urbandale

2901 86th Street
Urbandale, Iowa 50322

Closed Patients
Waiting Now

Kidney Transplant Referral

You can be referred to the Iowa Methodist Transplant Center for an evaluation by your nephrologists, dialysis unit or a self-referral.

To begin the referral process, please answer the following questions and complete the Kidney Transplant Recipient Referral form below. In addition, please complete the Authorization for Release of Health Information, Dental Clearance form and Informed Consent for Kidney Transplant Recipient form and either fax or mail the forms back to the Transplant Center. These forms must be completed and sent back to the Transplant Center before an evaluation will be scheduled.

Mail:
Iowa Methodist Transplant Center
1215 Pleasant Street, Suite 506
Des Moines, IA 50309

Fax:
(515) 241-4100

Required Forms

Authorization for Release of Health Information
Dental Clearance Form
Dental Clearance Form (Spanish)
Informed Consent for Kidney Transplant Recipient
Informed Consent for Kidney Transplant Recipient (Spanish)

Kidney Transplant Recipient Referral form


Personal Information


Sex *
Is it ok to leave a message on the phone numbers provided? *

Designated Support Person

One must be present at evaluation


It is ok to talk or leave a message with the contact listed above

Emergency Contact


It is ok to talk or leave a message with the contact listed above
It is ok to talk or leave a message with the contact listed above
It is ok to talk or leave a message with the contact listed above

Social History


Marital Status *

Advanced Directives

If Durable Power of Attorney for Health Care, Bring to Evaluation


Code Status *

Dialysis


Currently on Dialysis *
Type
If PD
Please choose
Days

Allergies


Immunizations/Preventative Health

Add the Date if known


Women Only

General Questions


Currently Working *
If Yes *
US Citizen *
Tobacco Use/History of Tobacco Use *
Do you use E-Cigarettes? *
Recreational Drug Use *
Alcohol Use/History of Alcohol Abuse *
Can you perform daily activities independently? *
Exercise Regularly
Willing to Accept Blood Products *

Family History

Please indicate Age/Current Health Status/Cause of Death of the following and if you or other family members have been adopted


Sex
Sex
Sex
Sex
Sex
Sex
Sex
Sex

Medical/Surgical History


Please choose
Do you have or have you ever been diagnosed with any of the following conditions? Select all that apply
Previous Blood Transfusion *
Previous Transplant *
Multiple Listed for Transplant *

Doctors


Kidney Doctor

Dialysis Unit

Check if not applicable

Heart Doctor

Check if not applicable

Cancer Doctor

Check if not applicable

Lung Doctor

Check if not applicable

Other Provider

Family Doctor

Pharmacy

Other Transplant Center

Other Transplant Center