DIALYSIS ACCESS REFERRAL FORM
TEL:  (832) 781 - 0000                Alex:            832-472-9888
FAX:  (832) 781 - 1000               Dr. Illig:        585-733-9225
www.flowvascular.com               Dr. Chang:   832-866-7145
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:

Nephrologist Phone Number:		  
 
Best Referral Contact:
Preferred FLOW Location
Current Access
Currect Access Location  None  Catheter  Fistula  Graft  PD
Side  Right  Left  Abdomen
What is the purpose of this referral?
            Office evaluation (we will triage by location but often see same day if desired):          
   New Access Consult  Hemo  PD  Either
   Catheter  Removal  Exchange  
   Steal/Hand Pain      
   Aneurysm      
   Other non-urgent problem:
             Evaluation and likely intervention to follow (we will traige by location but usually can be seen same day):
   High Pressure, bleeding  
   Arm swelling  
   Low flow, recirculation  
   Difficult Cannulation, pulling clots  
   Catheter not working  
   Acute aneurysm/pseudoaneurysm/hematoma/badstick  
               Potential acute surgical problem (will be sent to SSHA/Pasadena ER):  
   Clotted Access  
   Infection, skin breakbown  
   Active Ulceration, potential/actual bleeding  
   PD catheter disfunction  
   Other:
What is the purposeWhat is the purpose of this referral? of this referr
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       No