Download travellers welcome to toronto, ontario, canada

7300 WARDEN AVE, SUITE 103, MARKHAM, ONTARIO, CANADA, L3R 1Z6
TELEPHONE (905) 470-9992
FAX (905) 470-8086
1550 KINGSTON ROAD, UNIT 6, PICKERING, ONTARIO, CANADA, L1V 1C3
TELEPHONE (905) 831-1200
FAX (905) 831-9493
815 HIGH STREET, UNIT 7, PETERBOROUGH, ONTARIO, CANADA, K9J 8J9
TELEPHONE (705) 876-8737
FAX (705) 876-9060
TRAVELLERS
WELCOME TO TORONTO, ONTARIO, CANADA
GENERAL INFORMATION:
Since 1982 Dialysis Management Clinics Inc. have provided haemodialysis to travelling patients. As we are not
open at all times our answering service is available 24 hours per day. Please leave your phone number and name or
your mailing address and we will return your call or mail out an information package. Please confirm or cancel your
treatments by calling the clinic 48 hours before the first scheduled dialysis.
TREATMENTS:
WE DO NOT ACCEPT HEPATITIS B ANTIGEN OR MRSA/VRE POSITIVE PATIENTS
Maximum treatment time is 4 hours (or less as required).
Scheduling will be according to your requirements but is subject to change depending on other travellers and staff
availability. You may be examined by our Medical Director or associate during your stay with us and they will be
available to you on non-dialysis days.
Please re-confirm the treatment time 48 hours prior to your arrival.
MEDICATION:
Medication is not provided. Please bring your oral daily medication with you.
Intravenous infusion of medication will be given if drug is provided and is an approved drug (EPO, iron, calcijex &
antibiotics).
DRUGS ARE NOT PROVIDED. BRING THE REQUIRED DAILY DOSE FOR US TO ADMINISTER.
FOOD:
Hot and cold beverages are provided. You are welcome to bring a packed meal.
ENVIRONMENT:
ALL visitors to the unit are to wash hands upon entering unit. Patients experiencing respiratory symptoms
must check in with a nurse to assess need for mask. Visitors will not be allowed, if experiencing respiratory
or flu like symptoms.
Relatives and friends are permitted to visit if symptom free.
Radio, TV and telephone are available, but you must bring a head set. Long distance calls must be made collect.
We are located in a non-smoking building.
SPECIAL NOTE:
Travellers have arrived to our facility with high pre dialysis potassium. We may take chemistries on the first dialysis
and once a week depending on the length of your stay. Our Medical Director will recommend medication or changes
in treatment based on the results.
We hope you enjoy your stay with us and have a pleasant trip.
DMC-Ont. Jan 2012.
VISITOR PATIENT TRANSFER FORM
INFORMATION LIST
The enclosed forms should be completed and along with the requested reports, returned to us at least 2 weeks
prior to your first required treatment.
Incomplete information could result in a delay or a change or no confirmation in the scheduled treatments.
Please make copies of all this requested information. Mail, fax or email one copy at least 2 weeks prior to arrival.
The second set should then accompany the patient, as mail has been lost.
Use this list, as a reminder that all information requested has been included in your package.
Medical information sheets (our forms completed) __________
Physicians orders signed by the referring physician
______
(INCLUDING A LIST OF ALL MEDICATIONS TO BE GIVEN ON DIALYSIS AND BROUGHT WITH PATIENT)
Consent Form (enclosed)
3 most recent dialysis flow sheets (to be sent with request)
(Bring the last 3 most recent to the
unit on your first treatment)
Recent ECG report (within past year)
Recent X-ray report (within past year)
Recent History and Physical report
___________
Recent Pre and Post dialysis chemistries
____________
HbsAg neg. and HbsAb reports
_____________
MRSA, VRE reports (must be negative)
__________
Health Insurance Number
___________Version code:_________
PHONE NUMBER & CONTACT IN THE AREA
_______________________
DMC-Ont. Jan 2012
VISITOR PATIENT TRANSFER FORM
PATIENT CONSENT
1. I have been fully informed by my referring physician/nephrologist, of the surgical and medical procedures
and the problems and risks involved with haemodialysis.
2. I understand that haemodialysis involves, among other things, the insertion of needles into my veins and the
use of artificial kidneys to filter my blood.
3. I understand that Dialysis Management Clinics Inc., is an out patient facility and that only Level One patients,
as outlined by the Ministry of Health, may be dialysed in these facilities. In the event that I am no longer a
suitable candidate for this facility, I recognise that I will be transferred back to the referring hospital.
4. I hereby authorise and direct DR. P.Y. TAM/DR. B. NATHOO and/or assistants or associates of his
choice perform upon me haemodialysis and/or any other therapeutic procedures that their judgement may
dictate to be advisable for my health and well being.
5. This consent is for repeated haemodialysis treatment, and as such will be deemed effective for all
treatments received by me unless this consent is expressly revoked by me. However I understand that
chronic haemodialysis is a costly medical treatment and dialysis spots cannot be held vacant in the event
of prolonged hospitalisation or vacation.
6. I acknowledge that I have read the above consent and all other information regarding my dialysis
treatment at Dialysis Management Clinics, Inc.(also known as DMC) and that no guarantees have been
made to me concerning the results of this medical treatment.
6. I also acknowledge that my treatment schedule may be altered from time to time and that no guarantee
of a schedule has been made to me.
7. I further understand that by granting my consent for dialysis I agree to hold and save harmless Dialysis
Management Clinics, Inc., it staff and associates from any liability for any complications arising from the
dialysis treatment or medical conditions that may occur between dialysis.
I acknowledge that I have read the above consent and all other information regarding my dialysis treatment at
Dialysis Management Clinics Inc. and agree to comply with the policies and procedures at DMC.
PATIENT SIGNATURE:
WITNESS:
DATE:
SIGNATURE
(DMC REPRESENTATIVE
DMC-Ont. Jan 2012
)
CONSENT TO RELEASE OF HEALTH INFORMATION
I, ______________________________________________ (print name) of
________________________________________________________________________ (print address) hereby
authorize and consent to the release by DIALYSIS MANAGEMENT CLINICS INC. (DMCI) of all health
information (including all health records) regarding the undersigned patient which are in the possession of DMCI,
to the referring hospital ____________________________________, and its authorized physicians and staff for
the purposes of providing care to the undersigned patient. I further authorize and consent to the release to the
aforesaid information to other physicians and facilities as I may direct by couriers, telefacsimile &/or email.
I hereby release DMCI and each of its directors, officers, shareholders, employees and representatives from any
and all claims whatsoever which may arise as a result of the release of the above noted information.
It is acknowledged and agreed that information will be released only after the undersigned patient r an authorized
representative of the undersigned patient has paid DMCI any fees that may be deemed necessary for searching,
photocopying and telefaxing.
Dated this ______ day of _________________, 200__ .
Witness: ………………………………………………………………………
Signature
……………………………………….
NAME
…………………………………….
DATE
………………………………………………………………………………………………………..
ADDRESS
………………………………………
OCUPATION
Patient/Representative signature ……………………………………………………………………………..
Relationship to patient: ……………………………………………………………………………………….
This authorization/consent will be valid while I am at DMC I unless revoked by myself or my representative.
DMC-Ont. Jan 2012
VISITOR PATIENT TRANSFER FORM
PATIENT NAME:__________________
DATE:____________________________
Dialysis Management Clinics Inc. Ontario Traveller Form
MEDICATION
NAME:
..............................................................
..............................................................
..............................................................
..............................................................
..............................................................
DOSE:
............................
............................
............................
............................
............................
NAME:
................................................................
................................................................
................................................................
................................................................
................................................................
DOSE:
...........................
...........................
...........................
...........................
......................
OTHER INFORMATION (RELEVANT TO TREATMENT)
....................................................................................................................................................................................................
....................................................................................................................................................................................................
...............................................................................................................................................................................
DATE(S) REQUESTED
DAY:......................
DAY:......................
DAY:......................
DAY:......................
DAY:......................
DATE:.....................
DATE:.....................
DATE:.....................
DATE:.....................
DATE:.....................
DAY:......................
DAY:......................
DAY:......................
DAY:......................
DAY:......................
DATE:....................
DATE:....................
DATE:....................
DATE:....................
DATE:....................
REFERRING
FACILITY:.........................................................................................................................................
DIALYSIS
FACILITY CONTACT AND PHONE #:..............................................................................................................................
DOCTOR:................................................................................................. PHONE NO.:..............................................
PLEASE SEND WITH THE PATIENT THEIR SUPPLY OF EPO, VENOFER, CALCIJEX, ENGERIX.
AND ANY IV ANTIBIOTICS TO BE ADMINISTERED
DMC-Ont. Jan 2012
DOCTORS ORDERS
PATIENT
NAME:
HIN#________________
DIALYSIS ORDERS:
The following is available at DMC. PLEASE CHECK BOX or FILL IN THE APPROPRIATE SELECTION FOR THE
PATIENT. Other concentrate additives are not negotiable. Optiflux dialyzers are our stock item.
Treatment Time (Duration):____________ (minutes) ________times/week
DIALYSER: (Polysulfone): Optiflux 160NR

Optiflux 200NR

Target Weight: _____________ Kgs
Optiflux 250 NR

MACHINE SETTINGS:
Blood Flow Rate (BFR):___________mL/Min

or
POTASSIUM CHLORIDE: (mEq/L)
1

CALCIUM CHLORIDE: 1.50 mmol/L (3.0 mEq)

1.25 mmol/L (2.5 mEq/L)
Dialysate Flow Rate (DFR) (ml/min):
SODIUM BASE:__________(130-160)
500
2X BLOOD FLOW RATE
2
 Dialysate Temp:_____

3 

1.00 mmol/L (2.0 mEq)

SODIUM BICARBONATE: (30-40) ___________________
ANTI COAGULANT:
HEPARIN LOADING DOSE: _____________ HOURLY INFUSION:________________
STOP TIME: _______________ (prior to end of dialysis)
4% Sodium Citrate for CVL post: Arterial lumen:_______________mLs Venous lumen: ________________mls


MEDICATIONS ON DIALYSIS: CALCIJEX
YEARLY HX/PHYSICAL UPDATED: YES
NO
EPO/ARENESP/VENOFER/FERRLECIT
(please send copy to DMC)
(include dose, frequency & route)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
________________________________________________________________________________________________________CHE
MISTRIES: ( TO BE DRAWN @DMC)
Routine Chemistries (detail ranges eg. INR and Hgb targets)
WEEKLY: __________________INR TARGET_____
OTHER:_______________________________________
THIS PATIENT IS A LEVEL 1, AND IS FIT TO DIALYSE
IN
AN OUT OF HOSPITAL SETTING:
DOCTORS SIGNATURE: _________________________
DMC-Ont. Jan 2012
DATE: ___________________
DMC-Ont. Jan 2012