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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