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Add Addressograph/Label
Add Name & Address of Vascular Access Clinic
Phone #: _______________ Fax #: ________________
ATTENTION: VASCULAR ACCESS NURSE
REFERRAL TO VASCULAR ACCESS CLINIC
Please include: List of allergies (or copy of caution sheet), current medications, results of current blood
work, current access flow measurement log, vascular access history, 3 most recent run sheets & MOST
status (Medical Orders for Scope of Treatment).
Patient’s Phone Number: ______________________
Centre Referred From: __________________
Date of referral: _____________________________
Renal Area Referred From:_______________
Responsible Nephrologist:_____________________
Interpreter required:
No
Yes
If required, language: ___________________________
Hemodialysis Schedule:
Hemodialysis Time:
Mon
Tues
KCC Clinic
Transplant Clinic
Nephrologist’s Office
HD In-Centre Unit
PD Clinic
Community Unit
Other:_____________________________________
Wed
Thurs
Fri
Sat
Sun
Cause of Renal Failure: _______________________________________________________________
Known Antibiotic Resistant Organisms:
Current Access:
Side:
Location:
Left
Fistula
MRSA
VRE
Hepatitis B
Hepatitis C
Assessment for:
Right
Graft
Upper Arm
Lower Arm
Thigh
Int Jugular
Subclavian
Femoral
Infection Status:
Perm
Cath
Temp
Cath
Aneurysm
Limb/Face Swelling
Clotted
Low Access Flow
Difficulty Needling
Pain
Excessive Bleeding
Poor Art Flow
High CO Failure
Steal Syndrome
High Ven Press
Ultrasound mapping
Other______________________________
___________________________________
Reason for Referral:
Fistula Creation
Graft Creation
Catheter Placement
Fistula Revision
Graft Revision
Peritoneal Catheter
Problem Access Creation Date: ________________________
Cuffed
Non-cuffed
Insertion
Routine Assessment
Hospital: _______________________________
Other relevant information (please specify):
Signature: _____________________________________
FINAL June 21, 2007/Rev Jul 3, 2015
Date: ______________________________