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Patient Resources New Admission Form


If a travel/transient patient visits our the center, we require all this information, prior to their arrival. 

Click the link to download forms:


Dialysis unit visiting/transfer in patient form

Transient dialysis will be confirmed for your patient after receipt of this completed form and ALL required copies of information.


1. Personal Information


Name *

DOB *

Age

Address *

Phone No. *

SS#

Primary Insurer

Type

 

Secondry Insurer

Billing Phone

Contact

Address While Visiting There

Mobile No.

Mode of Transportation

To Destination

Arrival Date

From Destination

Departure Date

Treatment Dates Requested *

No. of Treatments

Contact No. *

Email Address *

Will be used only to send you a confirmation & map to our facility.

2. Home Dialysis Unit


Name

Address

Phone

Ext. #

Contact Person at Your Unit

Physician

Physician Phone


3.Dialysis Procedure


Access Site:

Subclavian - R.L.

Fistula - R.L.

Graft - R.L.

Date Created

First Use

Dialyser

Dialyzer Co Efficient

Dialyzer Allergies

Frequency (/Week)

Length of Treatment

Lines - Adult

Peds - Type

Dialysate:

NA

 

K+

 

CA

 

Other additives

Needles

Blood Flow

Dialysate Flow

Dry Weight (Kg)

Height (Cm)

Heparinization

Initial (Units):

Maintenance (Units)

Total Heparin Amount

Average Pre-Treatment BP

Average Post-Treatment BP

Average Weight Gain Between Dialysis

Average Fluid Replacement If Needed

Complications During Treatment And How Treated

4. Dialysis History


Type

Incenter

Incenter Self Care

Home Dialysis

Date of Initial Dialysis

Modality

5. Patient Medical Information


Diet

Protein

Na

Ka

24 Hours Fluid Restriction

URR

Date

Hepatitis Status of Patient

Hepatitis Status

Frequency of Hepatitis Testing

Has Patient Completed Hepatitis B Vaccine?

Hepatitis Antibody Titer

Date

HIV (if available)

Last Blood Transfusion

WRBC, PRBC, FRBC, Whole Blood

Is the patient a transplant candidate?

Transplant facility name and phone number

Allergies

Médication Allergies

Dialyser or Rebuse Allergies

Other Medical Information

Primary Language

Speak English

Ambulatory

 

Type of Assistance Required

Sensory Problems (Be Specific)

5. Patient History


Cause of Renal Failure

Is there a history of Seizure activity?

If yes last seizure

Other Diagnosis

Diabetic

 

Insulin Control

 

Dose

Hypertension

Pericarditis

Symptomatic Heart Disease

CHF

Valvular

Coronary Artery

Surgery in Last 12 Months

Other

Medication During / Post Dialysis (Dose & Frequency!!!)

Epo or Aranesp (Available)

Paricalcitol (Available)

Venofer (Available)

Hectorol (Available)

Other

If medication is every other week, or every two weeks. Please note if due while here!

Completed By *

Title *