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?