Full Name
Area Code
Phone Number
Date of Birth
Email
Dialysis Center
Telephone
Dialysis Day / Shift MWFTTSDaily / Home
Primary Nephrologist
Referred by
X-Ray Contrast Allergy? YesNo
Other Medication Allergy? YesNo
Blood Thinner or Bleeding Disorders? YesNo
Has patient had surgical revision of graft / fistula in last 4 weeks? YesNo
Known problem with anesthesia? YesNo
Competent to sign consent form? YesNo
Comment
Does the patient have their own transportation? YesNo
Does the patient need transportation arranged? YesNo
Please upload ANY additional information including insurance, demographics, and labs
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