Patient Referral Form
Enter the date of referral: -- mm/dd/yy
Please identify and describe the patient:
Name Facility Phone # Date of Birth
Name
Facility
Phone #
Date of Birth
Select any of the following options that applies:
Allergy to seafood Allergy to IV contrast History of Asthma On Antigoagulant (i.e. Coumadin) Transportation arrangements by DACC required
Allergy to seafood Allergy to IV contrast History of Asthma On Antigoagulant (i.e. Coumadin)
Transportation arrangements by DACC required
Reason For Referral:
High VDP Low Kt/V Low URR Arm Edema Clotted Access Dysfunctional Catheter
VDP @ Qb of 200?
Recirculation %?
Average Venous Pressure?
Average Arterial Pressure?
Enter your comments in the space provided below.
Which side is the access? Right Left
Choose the access site: Forearm Arm Thigh Neck
Choose one of the following: Straight Loop Cuffed Cath (Permcath) Non-Cuffed Cath