Referral Form North Shepherd Ambulatory Surgery Center Referral Form 5 Referral Form Step 1 of 4 25% Today's DateReferral Completed By(Required)Patient Name(Required)Patient Date of BirthAddressDialysis Center(Required)Last Dialysis TreatmentNephrologistDialysis Center PhoneDialysis Center FaxAccess Type Graft Fistula Catheter Access Location Right Left Chest Thigh Forearm Groin Upper Arm Evaluate and Treat Service Requested AVG/AVG IndicationAVG/AVG Indication Clotted Access - Date Clotted: Cold/Numbness/Pain Recirculation Infiltration Non-Maturing Fistula Aneurysm Low BFR Difficult Cannulation Abnormal Functional Studies Weak Thrill/Bruit Prolonged Bleeding Swollen Extremity Studies Low Kt/V Other Catheter Procedure RequestedDate of insertionType Tunneled Non-tunneled Desired Procedure Insertion Catheter Exchange Removal Facility Where PlacedSite Left Right IJ Groin Subclavian Indication Clotted Poor Function Broken Catheter No Longer Required Exchange temporary catheter for permanent catheter Other Clinical InformationX-Ray Contrast Allergy? Yes No ReactionDiabetic? Yes No If yes, is the patient on insulin?Anticoagulants? Yes No If yes, what type?Competent to Sign Consent? Yes No If no, whom?Is the patient ambulatory? Yes No Wheelchair? Yes No Stretcher? Yes No This field is hidden when viewing the formPDF
