Download for apppointment scheduling, we must receive this completed form

METROLINA NEPHROLOGY ASSOCIATES, PA
VASCULAR ACCESS CENTER REQUEST FORM
2711 Randolph Road, Bldg 400
Charlotte, NC 28207-2027
Phone: 704-971-8088
Fax: 704-971-8098
FOR APPPOINTMENT SCHEDULING, WE MUST RECEIVE THIS COMPLETED FORM ALONG
WITH MEDICAITON LIST.
Patient Name: __________________________________________ Dialysis Center: ___________________
Date of birth: _____/_____/20__
Patient Phone Number: __________________________________
ALLERGIES:
YES
NO
ALLERGY ALERT:
PATIENTS NEEDING A FISTULOGRAM- IF THEY HAVE AN ALLERGY TO IVP DYE- THEY
MUST RECEIVE PRE-TREATMENT MEDICATIONS OR THE CASE WILL BE CANCELLED AND
RESCHEDULED.
Diabetic:
Coumadin
YES
YES
NO
NO
Insulin:
YES
NO
Date of last Coumadin dose: _____/_____/20____
PATIENT HISTORY/PROCEDURE INFORMATION
Requested Procedure:
Declot
Fistulagram
Permcath insertion
Permcath removal
Post Procedure Ultrasound
Who placed access: ______________________________________ When? ____________________________
Change in character/thrill
Prolonged bleeding- How long?
Access arm edema/amount
Cannulation problems/describe
Access infection- Describe
Poor clearance
Other
Date of last dialysis:
Duration:
MWF
TTS