Davita ONLY - PD Catheter Insertion TEL:  (832) 781 - 0000 FAX:  (832) 781 - 1000 www.flowvascular.com

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:	DAVITA -   Tel:
Division:	Star WranglerAscent
Dialysis Day / Shift:	MWF      TTS      Daily / Home
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 ?	Hep B	Hep C	HIV	TB
Has patient had sprior abdominal surgeries?	Yes	No
Known problem with anesthesia?	Yes	No
Competent to sign consent form?	Yes	No