Identification Band Application
If you live in the Foundation’s service area, you or a medical provider can request a free identification band. Please allow two to four weeks for delivery. Questions? Contact Molly at
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Contact Information
Provide the contact information for the individual receiving the ID band.
First Name *
Last Name *
Mailing Address *
City *
State *
Zip Code *
Email Address
Phone Number *
Medical Information
Please provide the medical information for the individual receiving the ID band.
Which type of dialysis do you receive? *
Where is your access located? *
Name and contact information for person completing this application (if other than individual receiving ID band):
Any additional information you'd like to share?
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