Dialysis Access Center

Patient Referral Form

Enter the date of referral:    -- mm/dd/yy

Please identify and describe the patient:



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 

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?  

Choose the access site: 

Choose one of the following: 

Copyright 2000-2004 [DAC]. All rights reserved.
Revised: November 04, 2009