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* Indicates required question
1. Today's Date
Example: 01/12/2025
2. Patient Name *
3. Patient Date of Birth *
4. Is patient a resident of a nursing home? If yes, please use nursing home address and phone number for the patient's address and phone.
YesNo
5. Patient Phone Number *
6. Patient Address *
7. Primary Insurance
8. Primary Insurance Policy Number
9. Secondary Insurance
10. Secondary Insurance Policy Number
11. Dialysis Center Company *
US RenalDaVitaFresenius Medical CareAmerican Renal Associates (ARA)Other
12. Dialysis Facility Name *
13. Dialysis Facility Phone Number
14. Dialysis Facility Fax Number
15. Patient Dialysis Days Monday, Wednesday, FridayTuesday, Thursday, Saturday
16. Shift 1st2nd3rd
17. Date of Last Treatment
18. Is the patient on home dialysis? YesNo
19. Access Type AV FistulaAV Graft
20. AV Access Location RightLeft
21. Date of Access Creation
22. Procedure
Clinical EvaluationThrombectomyAngioplasty/Angiogram
23. Indication
InfiltrationClotted AccessNon-maturing FistulaHigh Venous PressureDifficult CannulationLow Blood FlowRecirculationPainProlonged BleedingSwollen ExtremitySteal SyndromePAVF Creation/ConsultOther
24. Procedure InsertionExchangeRemoval
25. Exchange/Removal Location
RightLeft
26. Indication Poor FunctionInfectionRepair (Broken Catheter)Clotted CatheterNo Longer NeededOther
27. Procedure PD InsertionPD ExchangePeritoneaogramPD RepairPD Removal
28. Indication
Poor FlowInfectionClotted Catheter
29. X-Ray Contrast Allergy? YesNo
30. What is the patient's reaction?
31. Blood thinner or bleeding disorders? YesNo
32. Type of blood thinner
33. Is the patient a diabetic? YesNo
34. Is the patient on insulin? YesNo
35. Is patient competent to sign consent?
36. If patient is not competent, please indicate the name and phone number of who may sign
37. Does patient have their own transportation?
38. Transportation Company
39. Transportation Phone
40. Is the patient ambulatory?
AmbulatoryCaneWalkerWheelchairStrecher
41. Post-procedure destination
HomeDialysis ClinicOther
42. Please upload all applicable medical record information, including insurance, demographics, and labs. Only the following file formats are supported: .jpg, .jpeg, .png, .pdf, .doc, and .docx. Each file must not exceed 1MB in size. Uploads that do not meet these requirements may be rejected.
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