Vascular Access Referral Forms

Hemodialysis Access FAX Referral: New Access – 3 Page Form

Part 1: Referral Fax - Communication tool from Nephrology office or dialysis facility to Surgeon/Interventional Radiologist that includes:

• Desired vascular access and site preference
• Diagnostic evaluations performed prior to referral
• Medical information – allergies, anti-coagulant use, recent labs, etc.

Part 2: Access Placement Results - Communication tool from Surgeon/Interventional Radiologist to Nephrology office of dialysis facility that includes:

• Type and location of newly placed access
• Directional flow of new access
• Access diagram
• Additional information

Hemodialysis Access FAX Referral: Existing Access – 2 Page Form

Part 1: Referral Fax - Communication tool from Nephrology office or dialysis facility to Surgeon/Interventional Radiologist that includes:

• Patient specific vascular access orders
• Medical and treatment information – allergies, access history, access problems, dialysis schedule, recent labs, etc.
• Option of ordering "Fistula Only"

Part 2: Access Placement Results - Communication tool from Surgeon/Interventional Radiologist to Nephrology office of dialysis facility that includes:

• Type and location of newly placed access
• Directional flow of new access
• Access diagram
• Additional information