Date

MM

DD

YYYY

Name of Applicant *

First Name

Last Name

Gender:

Male

Female

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Alternative Phone Number: *

(###)

###

####

What is your link to kidney disease?

Patient

Family

Medical provider/ team member

Other

Do you certify that the potential recipient of LAKE lives in the general area of Northeast South Dakota or Midwestern Minnesota?

Yes

No

Reason services are necessary (reasonably confirmed by neutral outsider, for example, social worker):

Financial strain

Lack of access to travel

Unplanned illness or burden

Other

Do you grant permission for us to talk to your care team or social worker?

Yes

No

Have you received LAKE services before?

Yes

No

Would you be willing to share your experience regarding kidney disease with others?

Yes

No