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UnityPoint Clinic - Express (Ankeny)

1055 Southwest Oralabor Road
Ankeny, IA 50023

Closed Patients
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UnityPoint Clinic - Express (Jordan Creek)

180 Jordan Creek Pkwy
West Des Moines, IA 50266

Closed Patients
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UnityPoint Clinic - Express (Waukee)

950 E Hickman Rd
Waukee, IA 50263

Closed Patients
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UnityPoint Clinic Behavioral Health Urgent Care - Des Moines

1250 East 9th Street
Des Moines, IA 50316

Closed Patients
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UnityPoint Clinic Urgent Care - Altoona

2720 8th Street Southwest
Altoona, IA 50009

Closed Patients
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UnityPoint Clinic Urgent Care - Ankeny Medical Park

3625 North Ankeny Boulevard
Ankeny, IA 50023

Closed Patients
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UnityPoint Clinic Urgent Care - Ingersoll

2103 Ingersoll Avenue
Des Moines, IA 50312

Closed Patients
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UnityPoint Clinic Urgent Care - Merle Hay

4020 Merle Hay Road
Des Moines, IA 50310

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UnityPoint Clinic Urgent Care - Southglen

6520 Southeast 14th Street
Des Moines, IA 50320

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UnityPoint Clinic Urgent Care - Urbandale

5200 NW 100th Street
Urbandale, IA 50322

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Kidney Transplant Patient Referral

Patients may be referred to the Iowa Methodist Transplant Center for evaluation by their nephrologist or dialysis unit, or they may contact the Transplant Center directly (self-referral).

Please complete and submit the online referral form below. You may also print the referral form and fax it to the Transplant Center at (515) 241-4100.


Required Forms

Before an evaluation will be scheduled, the following forms must be completed and sent back to the Transplant Center.

Health History 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