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UnityPoint Clinic - Express (Ankeny)

1055 Southwest Oralabor Road
Ankeny, IA 50023

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UnityPoint Clinic - Express (Jordan Creek)

180 Jordan Creek Pkwy
West Des Moines, IA 50266

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UnityPoint Clinic - Express (Waukee)

950 E Hickman Rd
Waukee, IA 50263

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1250 East 9th Street
Des Moines, IA 50316

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UnityPoint Clinic Urgent Care - Altoona

2720 8th Street Southwest
Altoona, IA 50009

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UnityPoint Clinic Urgent Care - Ankeny Medical Park

3625 North Ankeny Boulevard
Ankeny, IA 50023

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UnityPoint Clinic Urgent Care - Ingersoll

2103 Ingersoll Avenue
Des Moines, IA 50312

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UnityPoint Clinic Urgent Care - Merle Hay

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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. To begin the evaluation process, please answer the following questions. In addition, please complete the Authorization for Release of Health Information and Informed Consent for Evaluation of Donation and either fax or mail the forms back to the Transplant Center.

We will call you after receiving and reviewing your application. Please call us at (515) 241-4044 if you have any questions. 

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
Informed Consent for Evaluation of Donation




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