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UnityPoint Clinic - Express (Ankeny)

1055 SW Oralabor Rd
Ankeny, Iowa 50023-1280

Closed Patients
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UnityPoint Clinic - Express (Jordan Creek)

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

Closed Patients
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UnityPoint Clinic - Express (Waukee)

950 E. Hickman Road
Waukee, Iowa 50263

Closed Patients
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Urgent Care - Altoona

2720 8th St. SW
Altoona, Iowa 50009

Closed Patients
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Urgent Care - Ankeny

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

Closed Patients
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Urgent Care - Ingersoll

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

Closed Patients
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Urgent Care - Lakeview

6000 University Avenue
Suite 101
West Des Moines, Iowa 50266

Closed Patients
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Urgent Care - Merle Hay

4020 Merle Hay Road
Suite 100
Des Moines, Iowa 50310

Closed Patients
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Urgent Care - Southglen

6520 SE 14th St.
Des Moines, Iowa 50320

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Urgent Care - Urbandale

5200 NW 100th Street
Urbandale, Iowa 50322

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).

To begin the referral process, please complete the referral form and fax it to the Transplant Center at (515) 241-4100 or send to UPH_Transplant@unitypoint.org

Kidney Transplant Referral Form

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

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)

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