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Tennessee Kidney Foundation

Empowering and supporting those at risk or affected by kidney disease

Please note TKF’s new mailing address: P.O. Box 330989, Nashville, TN 37203 and shipping address: 1600 Hayes Street, Suite 300, Nashville, TN 37203.

What is Kidney Disease?
Support TKF
- Donate
  - Monthly Giving Campaign
- Volunteer
Get Help
About
- Leadership and Job Opportunities
- Programs
Events
Contact

What is Kidney Disease?
Support TKF
- Donate
  - Monthly Giving Campaign
- Volunteer
Get Help
About
- Leadership and Job Opportunities
- Programs
Events
Contact

TKF Kidney Screenings

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TKF Kidney Screenings

Screening Participant Intake Form

Contact Information (13 questions):
1. Name*
First MI Last
2. Email
3. Phone Number*
4. Address*
Street Address Address Line 2 City State ZIP Code
Participant Demographics:
5. Current Age
6. Identify as
- Woman
- Man
- Nonconforming/Nonbinary
- Transgender
- Not listed
- Prefer not to answer
7. Race
- White/Caucasian
- Black/African American
- American Indian/Alaska Native
- Native Hawaiian/Pacific Islander
- Other
- Prefer not to answer
8. Ethnicity
- Hispanic
- Non-Hispanic
9. Do you have a doctor or primary health care provider?
- Yes
- No
10. When was the last time you saw your primary care physician?
- Less than a year ago
- 1-3 years ago
- More than 3 years ago
- Never
11. Has a doctor ever told you that you had any of the following: (check all that apply)
- Polycystic kidney disease
- Kidney disease
- Lupus/ Lupus Nephritis
- Kidney stones
- Diabetes
- Heart disease
- High blood pressure
- High cholesterol
- Stroke
- None of the above
12. Has a blood relative ever been diagnosed with the following:
- Polycystic kidney disease
- Kidney disease
- Lupus/ Lupus Nephritis
- Kidney stones
- Diabetes
- Heart disease
- High blood pressure
- High cholesterol
- Stroke
- None of the above
13. Screening Consent and Release Form
You are participating in a free, voluntary kidney disease awareness screening provided by the Tennessee Kidney Foundation. The purpose of this screening is to find out if you are at increased risk for kidney disease or if you are showing signs and symptoms of kidney disease. This program is for informational and educational purposes and it is not a diagnosis or a medical treatment. This screening is not a substitute for consulting your health care professional.
Participants must be 18 years or older and sign this release form giving Tennessee Kidney Foundation permission to perform the screening test. Participants13-17 may be screened with a parent or guardian present. You may withdraw from the screening process at any time. All information about you, your answers to questions and your results are confidential. To protect your privacy, you will be assigned a Participant ID number. This number will be used to identify you whenever possible. Your name, your participant ID and the results relating to you may be provided to researchers or safety and privacy review boards.
By checking the box for consent below, I voluntarily agree to participate in this screening, and I give permission for the screening to be performed. I also agree that I will not hold Tennessee Kidney Foundation, its officers, directors, employees, or volunteers liable for any demands, claims, and/or judgments that might arise as a result of my participation here today.
I have read, or had read to me, all of the material contained in this release form, and I understand what it says. By checking the box below, I attest that I agree to all of it.
- I give my consent.
Date
MM slash DD slash YYYY
By checking the box below, I give permission to be photographed during the screening event and give consent to the use of my photograph by Tennessee Kidney Foundation. I understand that my photograph will not necessarily be used by virtue of this consent.
- I give my consent.

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Sign Up to Volunteer

Screenings Volunteer Signup

Please select the volunteer opportunity you'd like to help with:
- Fundraising (Up Next: Kidney Disease Awareness / Monthly Donor Campaign - March 2021)
- Special Event Volunteer (Up Next: Gala – Saturday, June 19, 2021)
Please provide your preferred screening volunteer assignment:
Name
First Last
Address
Street Address Address Line 2 City State ZIP Code
Phone
Email
Phone
This field is for validation purposes and should be left unchanged.

Lindsey Collier

I volunteer with the TKF because 1 in 3 American adults are at risk for kidney disease and I know the TKF relies on individuals in the community to step-up and freely give their time in order to help sustain its empowering programs for those at risk or affected by kidney disease in our TN communities. I truly believe the volunteer work I do with the TKF is vital to ensuring this marginalized group receives the critical support needed to positively impact their livelihood.

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