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 info@kfohio.org.

Recipient Information

Provide the contact information for the individual receiving the ID band.

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

County *

Phone Number *

Email Address

Which type of dialysis do you receive? *

Hemodialysis

Peritoneal dialysis

Other Other

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?