Get the free Peritoneal Dialysis Referral Form 2015 - STG RENAL - stgrenal org

PERITONEAL DIALYSIS REFERRAL Country of Birth PATIENT NAME Address: MAN DOB AGE Phone: Doctor Significant Other: Phone: Or affix Patient Identification Label here Date Of Referral: Creatinine on commencement

How to fill out peritoneal dialysis referral form

How to fill out a peritoneal dialysis referral form:

1. Contact Information: Start by providing your full name, address, phone number, and email address. This information is important for the healthcare provider to reach out to you.
2. Primary Care Physician (PCP): Write the name and contact details of your primary care physician. It helps in coordinating your medical care and ensuring proper communication.
3. Reason for Referral: Indicate the reason why you need a peritoneal dialysis referral. It could be due to kidney disease, end-stage renal disease (ESRD), or other related conditions. Be clear and concise in explaining your condition.
4. Medical History: Provide a comprehensive medical history, including any existing health conditions, previous surgeries, allergies, and medications you are currently taking. This information assists the healthcare provider in evaluating your suitability for peritoneal dialysis.
5. Insurance Information: Include details about your health insurance provider, policy number, and any related authorizations or approvals required for coverage.
6. Test Results: Attach copies of any relevant test results, such as blood work, urinalysis, or imaging scans that support the need for peritoneal dialysis.
7. Referring Physician Information: If you have been referred by a specific physician or specialist, make sure to include their name, contact details, and any additional notes or instructions they have provided.
8. Signature and Date: Finally, sign and date the referral form to indicate your consent and understanding of the information provided.

Who needs a peritoneal dialysis referral form?

1. Patients with kidney disease: Individuals diagnosed with kidney disease may require peritoneal dialysis as a treatment option. The referral form is necessary for accessing specialized care and initiating the dialysis procedure.
2. Individuals with end-stage renal disease (ESRD): Peritoneal dialysis is a common treatment for people in the advanced stages of kidney failure. A referral form is needed to facilitate the process and ensure proper management of the condition.
3. Patients seeking alternative dialysis options: Some individuals may prefer peritoneal dialysis over other dialysis methods, such as hemodialysis. In such cases, a referral form helps in streamlining the decision-making process and accessing the preferred treatment.

Remember, it is always best to consult with your healthcare provider or medical team for specific instructions on filling out a peritoneal dialysis referral form as requirements may vary.

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