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:	US RenalDavitaFMCARA* Other -   Tel:
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

Transportation Needs

Does the patient have their own transportation?     Yes      No Does the patient need transportation arranged?     Yes      No