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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