Living Donor Application | Iowa Methodist Transplant Center

UnityPoint Clinic - Express

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

01 Patients
Waiting Now

UnityPoint Clinic Urgent Care - Altoona

2720 8th St. SW
Altoona, Iowa 50009

07 Patients
Waiting Now

UnityPoint Clinic Urgent Care - Ingersoll

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

04 Patients
Waiting Now

Urgent Care - Ankeny

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

06 Patients
Waiting Now

Urgent Care - Lakeview

6000 University Avenue
Suite 101
West Des Moines, Iowa 50266

02 Patients
Waiting Now

Urgent Care - Merle Hay

4020 Merle Hay Road
Suite 100
Des Moines, Iowa 50310

02 Patients
Waiting Now

Urgent Care - Southglen

6520 SE 14th St.
Des Moines, Iowa 50320

01 Patients
Waiting Now

Urgent Care - Urbandale

2901 86th Street
Urbandale, Iowa 50322

01 Patients
Waiting Now
Living Donor Form | Iowa Methodist Transplant Center

Living Kidney Donor

Thank you for your interest in becoming a living kidney donor at the Iowa Methodist Transplant Center. Please answer the following questions. We will call you after receiving and reviewing your application. Please call us at (515) 241-4044 if you have any questions. 



Patient Information


Sex *
Is it ok to leave a message on the phone numbers provided? *
Best time to contact
I am interested in becoming a humanitarian donor *
Do you have someone in mind for your donation? *
Marital Status *
Do you have an advanced directive? *
Are you employed? *
If yes

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

Medical History


Do you have problems with blood sugar/diabetes?
Did you have blood sugar problems/diabetes during pregnancy?
Are you currently being treated for High Blood Pressure?
Do you take blood pressure medication?
Were you treated for High Blood Pressure during pregnancy?
Do you have heart problems?
Do you have a history of kidney stones/problems?
Do you have a history of urine/kidney infections?
Have you ever had cancer?
Please choose
Do you have or have you ever been diagnosed with any of the following conditions? Select all that apply
Do you use tobacco or have a history of tobacco use? *
Do you use recreational drugs? *
Do you drink alcohol or have a history of alcohol abuse? *
Can you perform daily activities independently? *
Can you exercise regularly?
Are you willing to accept BLOOD PRODUCTS if needed? *

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

Other