Application

The following information must be included when referring a patient for a kidney transplant evaluation:

1. Current application
2. Evaluation request signed by the patient's referring Nephrologist.
3. Current transplant history and physical from the referring Nephrologist which includes the following:
   • Review of systems
   • Notation of discussion of transplantation with the patient
   • Statement of eligibility for kidney transplant.
4. Current laboratory results
5. Initial dialysis Social Worker evaluation.
6. Initial dialysis Dietitian evaluation.
7. Legible copy of insurance cards (both front and back), Medicare, and Medicaid.
8. Any additional information to assist in determining suitability for transplantation.

Please mail all of the above to:
Texas Health Harris Methodist Hospital Fort Worth
Kidney Transplant Program
1301 Pennsylvania Avenue
Fort Worth, TX 76104

For questions, please call 817-250-2443 or 800-411-2443.

You may fax additional information throughout the workup process to 817-250-5136.

Downloads (PDF)

• Kidney Transplant Program Recipient Application
• Kidney Transplant Program Donor Application