DIALYSIS REFERRAL

NKDHC Central Admissions
Attn: Jessica Jones
Email: jjones@nkdhc.com
Phone: (702) 375-3248
Fax: (866) 404-8693

PATIENT INFORMATION
*Patient Last
*Patient First   MI:
*Patient Phone (daytime)
  Phone (evening)
*Birth Date
*Insurance Plan
*Referring Hospital Name
*Dialysis Modality
Patient Status

CONTACT INFORMATION
*Case Manager Name
*Contact Number
  Contact Fax Number
  Contact Email

ORDERING PHYSICIAN INFORMATION
*Ordering Physician Name
  Practice Name
  Physician Phone Number

Additional Dialysis Placement Information
Notes
(500 ch)
    
*Required Fields