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