REFERRAL FOR LONG-TERM RENAL FOLLOW-UP FOR PATIENTS RECEIVING
RENAL REPLACEMENT THERAPY FOR AKI ON PICU
Please fill in the details as requested and FAX to number below – this form acts as
the referral letter to the Paediatric Nephrologists.
Patient name /dob/ address
(affix hospital identity label)
Phone No
Type of renal replacement therapy and dates of therapy
CVVH:…………………………………………………………………………………………
PD: ……………………………………………………………………………………………
Intermittant HD: ……………………………………………………………………………
Reason for RRT (tick all that apply)
Electrolyte disturbance
Fluid removal
Toxin removal
Metabolic condition
Please do NOT book investigations. Paediatric Nephrologist will do this.
Referring Doctor:
Name:
……………………………
Designation:
………………………..
Date:
…………………………….
Hospital: ……………………………………………..
Please send form together with a copy of the patient’s discharge summary to Kelly
Gillingham Renal Assistant to Paediatric Renal Team, E17 Children’s Renal & Urology
Unit, QMC Campus. (Phone ext: 61414, fax 0115 9709410; internal 61410)
Tracking for notes: Q-PRUSEC