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Methodist Dallas Medical Center Recipient Application for Organ Transplant
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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Application for (check all organs that apply):
*
Kidney
Pancreas
Liver/Kidney
Do you have a possible living donor?
Yes
No
PHYSICIAN INFORMATION
Your kidney doctor (Nephrologist)
*
Nephrologist Address
Nephrologist Phone Number
*
Format: (000) 000-0000.
Primary Care Physician Name
Primary Care Physician Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Primary Care Physician Address
PATIENT INFORMATION
FIRST
*
LAST
*
MIDDLE
MAIDEN (If applicable)
SOCIAL SECURITY (optional)
STREET ADDRESS
UNIT/APT
CITY
STATE
ZIP
Home Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Mobile Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Age
Sex
Religion
Race
Marital Status
Single
Married
Separated
Divorced
Widowed
Patient employed by
Work Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Is patient a U.S. Citizen or permanent resident?
Yes
No
What country?
Does the patient speak English?
Yes
No
What language?
Work Status
Full Time
Part Time
Retired
Disabled
ADDITIONAL CONTACT INFORMATION
Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to patient
MEDICARE/MEDICAID INFORMATION
MEDICARE ID
Effective Date
-
Month
-
Day
Year
Date
Medicare due to:
Kidney disease ESRD
Age
Other
Medicaid ID
Effective Date
-
Month
-
Day
Year
Date
Texas Kidney Healthcare I.D. (Texas residents only)
INSURANCE INFORMATION
Insurance
HMO
PPO
POS
Indemnity
Effective Date
-
Month
-
Day
Year
Date
Insurance Company Name
Name of Group Employer
Group
Policy
Insurance Benefits Phone Number
Format: (000) 000-0000.
Insurance Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of insured person
Relationship to patient
Date of Birth of insured person
-
Month
-
Day
Year
Date
SS of insured person
Are you currently listed at another transplant center?
Yes
No
Center Name
DIALYSIS INFORMATION
Primary diagnosis example diabetes FSGS hypertension
Currently on dialysis?
Yes
No
Date current dialysis began:
-
Month
-
Day
Year
Date
Type of dialysis:
Home hemo
PD
In-center Hemo
Dialysis center
Address
Phone number
Format: (000) 000-0000.
Dialysis Shift
Mon Wed Fri
Tues Thurs Sat
Shift
1
2
3
4
Nocturnal
Previous organ transplant?
Yes
No
Organ transplanted?
Kidney
Pancreas
Liver
Other
Date of transplant
-
Month
-
Day
Year
Date
Transplant hospital
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
Should be Empty: