Humble Vascular Surgical Center Interventional Nephrologist & Interventional Vascular Specialist located in Humble, Texas.

Ruchdi Barakat, MD
Brett Stephens, MD
John Nguyen, DO
Christopher Durham, MD

humblevascularsurgicalcenter.com 

REFERRAL FORM 

PH 346-616-5862

Fax 281-570-2579
Send Email:
HVSC@surgerypartners.com
 
Today's Date: Requested Procedure Date: Last HD Treatment:
 

Patient Information
Patient First Name:
Patient Last Name:
Patient Phone:
Patient DOB:
 
 

Dialysis Center Information
Dialysis Treatment Center: Treatment Center Location: Treatment Center Phone: Treatment Center Fax:
Dialysis Day:  MWF  TTS  Daily / Home
Dialysis Shift :  1st  2nd  3rd
Primary Nephrologist:
Form Completed by:
 
Isolation
Isolation Precautions?  Yes      No
Contagious Diseases?  Hep B     Hep C     HIV     C-Diff     MRSA     COVID     Other
 

Access Procedure: AV Graft / AV Fistula

Type of Access:

 AV Graft

 AV Fistula      HeRO      Catheter 

Catheter Location:

 Right

 Forearm      Upper Arm      Femoral

 

 Left

 Chest      Abdomen

Desired Procedure:

 Declot

 Angiogram (Fistulogram / Graft Angiogram)     

 

 

 AVF Creation

Notes:

Indication:

 High Venous or Arterial Pressure     Difficult Cannulation     Pulling Clots     Prolonged Bleeding

 

 Recirculation     Non-Maturing Fistula     Pain     Swollen Extremity     Infiltration

 

 Access Surveillance     Permanent Access     Clotted Access     Steal Syndrome     Aneurysm   
 

Catheter Procedure
Site:
 Tunneled
  Non-Tunneled
Catheter Location:
 Right      Left
  Chest      Abdomen      Femoral
Desired Procedure:
 Insert
  Exchange       Remove
Indication:  Poor Function      No Longer Required      Infection      New Patient / Modality Change
   Broken Catheter      Clotted Catheter      Painful Catheter
   Exchange Temporary Catheter for Permanent      Other
 

Clinical Information
Diabetic?  Yes     No
X-Ray Contrast Allergy?  Yes     No
Other Medication Allergy?  Yes     No
Anticoagulants?  Yes     No
Has patient had a surgical revision of graft / fistula in the last 4 weeks?  Yes     No
Known problem with anesthesia?  Yes     No
Competent to sign consent?  Yes    No
If patient is unable to sign, do they have a POA?  Yes     No
 

Transportation Needs
Will patient provide their own transportation?  Yes      No
HVSC Arranged Transportation?  Yes      No
Is patient ambulatory or require a mobility aid?  Ambulatory      Cane     Walker      Wheelchair      Stretcher
Post-Procedure Destination:  Home      Dialysis Center       Other

The following should be attached when submitting this form: Insurance Cards, Demographic Sheet, Medication List, Hemoglobin and Potassium.