Filling out the Online Referral Form

The Online Referral Form has six parts:

1. Access Center Information
2.  Patient Information
3. Access Type
4. Clinical Information
5. Dialysis Center Info
6. Additional Notes and Instructions

Information about the patient and the dialysis facility are prepopulated for you, although you can override those values.  You cannot change the patient name or medical record number.   You can also leave fields empty to fill in after you print the form out.

Access Center Information

This section is for basic information about the Access Center. 

Patient Information

This section holds information about the patient

Access Type

Some stuff about the access type part of the form

Clinical Information

Some stuff about the Clinical Information part of the form

Dialysis Center Info

Some stuff about the dialysis center part of the form

Additional Notes and Instructions

Some stuff about the notes part of the form