Referring Physicians

Thank you for referring your patient to us. In addition to this online request please fax us at 919-908-6081 the following from:

Carolina Vascular Access Referral Form (PDF file).

All of the following are required to be faxed to Carolina Vascular Access for an Appointment to be made: Signed Order, Demographic Sheet, Medication List, Most Recent H&P, List of Allergies, Insurance Info.

Referral Form

Dialysis Center: Phone Number*: Fax Number

Today's Date*: Desired Procedure Date*:

Patient Name* (required) DOB:

Patient Phone: Patient Address:

Nursing/Rehab Facility:

Emergency Contact: Phone Number:

Ordering Provider: Nephrologist:
Is the Patient Able to Dialyze: YesNo    Last Dialysis Treatment: Surgeon:

Fistula or Graft

Type of Access:        When Was the Access Placed:

Site/Location:

Desired Procedure:

***If coming for maturity evaluation or is a new access, we MUST know the date the access was placed and surgeon!!***

Indications:

Catheter

Type of Catheter:     When Was the Access Placed?

Site/Location:

Desired Procedure:

Indication:

Clinical

IV Dye, Contrast, or Shellfish Allergy? Reaction?

Diabetic? YesNo

Any Anticoagulants:

Competent to Sign? By Whom? Phone:

Does Patient Have VA Insurance?

Transport

Does Patient Require a Hoyer Lift?

How Does Patient Transport to Dialysis?

Who Will Transport Patient to CVA?

How?