Body Donation Application and Inquiry

"*" indicates required fields

Apply Online or Request More Information About Body Donation

Complete the form below to request information or apply for the Des Moines University Medicine and Health Sciences Body Donation program. You can start your application online or request more information by mail or email.

Are You Inquiring/Applying on Behalf of an Individual Who Cannot Provide Their Own Consent?*

Yes

Request Inquiry or Begin Application?*

Request a mailed/emailed inquiry or begin your body donation application online.

Request Mailed Inquiry

Request Electronic Inquiry

Begin Online Application

Contact Us To Get Started

If you are inquiring or applying on behalf of an individual who cannot provide their own consent, you must contact the body donation program at 515-271-1481 for further instructions.

Personal Information Pertinent to Body Donation

Legal Name*

First Middle Last

Date of Birth*

Month

Day

Year

Mailing Address*

Street Address City State ZIP Code

Phone*

Email*

Number of Informational Packets*

How many informational packets would you like us to mail?

Please enter a number from 1 to 10.

Once your inquiry request is submitted, the Body Donation program will mail the requested number of informational packets to the address provided above.

Note: Request materials are mailed on a weekly basis.

Once your inquiry request is submitted, the Body Donation program will share the following documents via email:

Informational Brochure
Anatomical Gift Procedures
DMU Anatomical Donation Application
DMU Anatomical Donation Consent Form

Note: Requests are emailed on a weekly basis. This option requires you to print and return the DMU Anatomical Donation Application and DMU Anatomical Donation Consent Form for submission. Please refer to the Anatomical Gift Procedures document for submission instructions.

This field is hidden when viewing the form

Application Fields

Gender*

Male

Female

Current Marital Status*

Single

Married

Divorced

Widowed

Separated

Domestic Partnership

Spouse or Partner Name*

First Middle Last

Main Occupation for Most of Donor’s Life*

Industry of the Donor’s Occupation*

Highest Level of Education Completed*

Are You a Veteran?*

Yes

Branch of Military Service*

Upload a Copy of Your Military Discharge

Max. file size: 10 MB.

Ethnicity*

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Other

Ethnicity — Other*

Are You an Organ/Tissue/Eye Donor?*

Yes

Medical History

Height (Inches)*

Weight (Pounds)*

Medical Conditions You Currently Have or Have Had*

N/A

Alcoholism/Drug Abuse

Allergies

Alzheimer's/Dementia

Arthritis

Atherosclerosis

Autoimmune Disease

Cancer

COPD/Emphysema

Depression/Mental Illness

Diabetes

Gallbladder Disease

Gastrointestinal Reflux Disease

Heart Attack

Heart Disease

High/Low Blood Pressure

High Cholesterol

Kidney Disease

Liver Disease

Hepatitis/Jaundice

Osteoporosis

Scoliosis

Sexually Transmitted Disease

Stroke

Thyroid Disease

Tuberculosis

Autoimmune Disease Type(s)*

Cancer Type(s)*

Any Other Medical Conditions Not Listed Above

Surgical History*

N/A

Amputation

Aortic Valve Replacement

Appendectomy

Cardiac Bypass Surgery

Cataract Surgery

Cesarean Section (Female)

Cholecystectomy

Dilation and Curettage (Female)

Hemorrhoidectomy

Hernia Repair

Hysterectomy (Female)

Joint Replacement

Mastectomy

Organ Transplant Surgery

Pacemaker Implantation

Prostatectomy (Male)

Spine Surgery

Tonsillectomy

Tubal Ligation (Female)

Vasectomy (Male)

Amputation Type*

Joint Replacement Type(s)*

Organ Transplant Type(s)*

Any Other Surgical Procedures Not Listed Above

Next-of-Kin Contact Information

Primary Contact Person’s*

First Last

Primary Contact’s Address*

Street Address City State ZIP Code

Primary Contact’s Phone*

Primary Contact’s Relationship to Donor*

Alternate Contact Person*

First Last

Alternate Contact’s Address*

Street Address City State ZIP Code

Alternate Contact’s Phone*

Alternate Contact’s Relationship to Donor*

Online Application Acknowledgements

When you submit your completed application, you will receive the Consent of Anatomical Gift to Des Moines University document via mail or email, depending on the delivery method indicated below.

This document must be executed within 14 days from the time of receivership and returned to the program office promptly to be considered for DMU’s Body Donation program.

Please Review the Following Statements*

I understand that this application is for myself only and no other individual.

I understand that the submission of this application will not be complete until I execute the Consent of Anatomical Gift to Des Moines University Form and return it to the program office within 14 days of receivership for consideration.

I understand that my application will be declined if the Consent of Anatomical Gift to Des Moines University is not completed accurately, fully and within the 14-day allotment.

I have reviewed and understand the statements above.

How Should We Send Your Consent Document?*

Mail a Hard Copy to the Mailing Address Entered Above

Email a Digital Copy to the Email Entered Above

Body Donation Application and Inquiry

Apply Online or Request More Information About Body Donation

Contact Us To Get Started

Personal Information Pertinent to Body Donation

Application Fields

Medical History

Next-of-Kin Contact Information

Online Application Acknowledgements

Contact DMU

Quick Links