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Methodist Dallas Medical Center - Kidney Living Donor Application
Required information must be filled out in order to process your application. If you are a referring office, you may upload application referral and supporting documents in lieu of completing online form. For assistance in filling out your application, please call 214-947-1800
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Recipient Information
Potential Donor For
*
Recipient Name
Relationship to Recipient
*
Relationship to Recipient
Donor Information
Donor Name (Your Name)
*
Your Name
Social Security #
Date of Birth
*
/
Month
/
Day
Year
Your Date of Birth
Sex
Male
Female
Race
Home phone number
*
Format: (000) 000-0000.
Cell phone number
Format: (000) 000-0000.
Additional phone numbers
Format: (000) 000-0000.
Email address
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Occupation
Are you currently working?
Yes
No
Are you currently disabled?
Yes
No
Are you currently retired?
Yes
No
Are you working full time?
Yes
No
Are you working part time?
Yes
No
Do you have health insurance?
Yes
No
What are the best days/times for appointments to be scheduled
Health Information
Name of Personal/Primary Care Physician
Dr.'s Office Phone Number
Format: (000) 000-0000.
Dr.'s Office Address
List all medications including dose and how often you take it
List all over the counter medications you currently take
List any Allergies
What is your height?
What is your current weight?
Is this your usual weight?
Yes
No
Date of last pap smear
/
Month
/
Day
Year
Date
Date of last mammogram
/
Month
/
Day
Year
Date
Have you ever had a colonoscopy (lower endoscopy) or EGD (upper endoscopy)?
Yes
No
When was your colonoscopy or EGD?
Why did you have a colonoscopy or EGD?
List any medical conditions/problems:
Have you had any surgeries?
Yes
No
Please list surgeries
Have you had any other hospitalizations?
Yes
No
If yes, please list hospitalizations
Donor Signature
*
Date
*
/
Month
/
Day
Year
Date
Submit
Completion of this application does not guarantee acceptance of such application and/or guarantee of any services provided by Methodist Dallas Medical Center, the Transplant Institute at Methodist Dallas, and/or any of its affiliates, including follow-up communications
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