Orbis Vascular · Orbis Surgery Center
Dialysis access referral
Clear form
For dialysis center staff. Choose your center, attach the referral, and answer what it does not already say.
1
Your dialysis center
Choose your center…
My center is not listed
Your name *
Your direct phone *
Your email
2
Referral
Referral
*
Drop the referral here - we'll fill in what we can
PDF, or photos of each page (JPG / PNG). Up to 20 MB each.
Insurance card (optional)
Drag the file here, or tap to choose
Front and back, if you have it.
3
Patient
Last name *
First name *
Date of birth *
Patient phone
Last dialysis treatment
Insurance
Member ID
Name on card
3
Shift
Days
MWF
TTS
Time
AM
MID
PM
Nocturnal
Chair time
4
Referred by
Referred by
Nephrologist
5
Access
Access type
AV Fistula
AV Graft
Catheter
Endo AVF
Location
Right
Left
Forearm
Upper Arm
Thigh
Chest
Groin
6
Desired procedure
Declot
Angiogram / Fistulagram / Graft Angiogram
Venogram (Vein Mapping)
Insert Catheter
Exchange Catheter
Remove Catheter
New Access Evaluation
Other
7
Indication
Clotted Access / No thrill/bruit
Aspirating Clots
High Venous Pressure
High Arterial Pressure
Difficult Cannulation
Steal Syndrome
Pain
Low URR or KT/V
Swollen Extremity
Catheter Dysfunction
Catheter Infection
Prolonged Bleeding
Non-Maturing Fistula
Low Access Flow
Aneurysm
Other
8
Clinical information
X-Ray contrast allergy
Yes
No
Other medication allergy
Yes
No
Diabetes
Yes
No
Blood thinner or bleeding disorder
Yes
No
Contagious diseases
Yes
No
Surgical revision of graft/fistula in the last 4 weeks
Yes
No
Known problem with anesthesia
Yes
No
Competent to sign consent
Yes
No
Patient weight over 400 lbs
Yes
No
9
Transportation
Patient has own transportation
Yes
No
Patient needs transportation arranged
Yes
No
10
Anything else
Notes
I am sending this referral for this patient's care at Orbis Vascular, and the information is correct to the best of my knowledge.
Send referral
Sent securely to Orbis Vascular. This page only shows what is in the file you attach here.