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Dialysis Application Form
Dialysis Application Form complete and send also the dialysis prescription form to be sent to: USL 7 - Ospedale Alta Val d’Elsa Poggibonsi (Si) - Italia Sezione di Nefrologia (Phone + 39 0577 994219; fax +39 0577 994205) Mr./Ms… ………………………….………….born…....…………….…in…………..………….… Address………………………………………………………………………………………… Kidney disease ……… …………………………. Has been treated in our dialysis center since….……………………….. Center address and phone number………………………………….………………………… N°....................... and date………………………of dialysis sessions requested Major clinical facts......................................................................................................................................................... ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ ................................................................................................................................................................ Vascular access…… ........................… Interdialytic weight gain……………..... Kg BP before dialysis...........….…….BP after dialysis………….... Intradialytic complications............................................................ HBsAg:… …………….Ab anti-HCV: ….……………… Ab anti-HIV…..…….………………… Intradialytic therapy: At home therapy Dr.
Documenti analoghi
HOLIDAY DIALYSIS REQUEST
HOLIDAY DIALYSIS REQUEST
(to be completed by doctor or dialysis unit staff)
PERSONAL DETAILS:
Name:
Surname:
Date of birth:
holiday dialysis request
N.B. This form has to be filled in in every part, if not, receiving
holiday nephrologist could deny the booking, being important
information on the dialysis performed by travelling patient missing....
