Vascular Access Evaluation
:  (832) 781 - 0000
FAX:  (832) 781 - 1000
Today's Date: Requested Procedure Date: Last HD Treatment:
 Patient Information
First Name Last Name
Patient Phone Date of Birth
Dialysis Center Information
Dialysis Center:    Tel
Dialysis Day / Shift:
Primary Nephrologist:
Referred by:

Preferred Flow

Vascular Access Type
Access Type:
Desired Procedure:  Declot      Angiogram (Fistulogram / Graft angiogram)     
 Clotted Access   Steal Syndrome  Pain  Prolonged Bleeding
 Aspirating Clots  Low URR or KT/V  Non-Maturing Fistula  Swollen Extremity
 High Access Pressure  Low Access Flow  Aneurysm  Difficult Cannulation
 Catheter Infection / Dysfunction    
Clinical Information
X-Ray Contrast Allergy?  Yes  No
Other Medication Allergy?  Yes  No
Blood Thinner or Bleeding Disorders?  Yes  No
Contagious Diseases ? 
Has patient had surgical revision of graft / fistula in last 4 weeks?  Yes  No
Known problem with anesthesia?  Yes  No
Competent to sign consent form?  Yes  No
Transportation Needs
Does the patient have their own transportation?     Yes      No
Does the patient need transportation arranged?     Yes