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Refer A Patient

Referral Form

Fill out the form below to refer a patient to us and our team will be in touch with you as soon as possible.

Get Started

1Patient Info

2Procedure Info

Patient Name:

Full Name

Date of Birth:

MM slash DD slash YYYY

Pt Home Phone:

Pt Cell Phone:

Which office are you requesting?

Dialysis Unit:

Nephrologist:

Insurance:

PCP Phone:

PCP Fax:

Allergies:

Coumadin/Eliquis/Xarelto:

Yes

Is the patient currently in a skilled nursing facility:

Yes

Facility Name:

Check all that apply

Dialysis Days:

M-W-F

T-TH-S

Dialysis Shift:

MID

Last treatment:

Access Type:

Catheter

Graft

Fistula

PD Cath

Current Access Flow:

Catheter:

Clotted Catheter

Catheter with Poor Flow

Catheter Removal

Infected Catheter

Peritoneal Dialysis Catheter Insert *New Service*

Peritoneal Dialysis Catheter Manipulation *New Service*

Peritoneal Dialysis Catheter Removal *New Service

Fistula/Graft/Vein Mapping:

Clotted Fistula/Graft NO THRILL/BRUIT

Venous Mapping for New Access Placement

Percutaneous Fistula Creation *New Service*

Non-Maturing Fistula

Fistula/Graft Evaluation

Other Issues/Complaints:

Aspirating Clots

Swelling of Arm

Poor Access Flows

Poor Clearance

Prolonged Bleeding

Difficulty Cannulating

Skin Marking for Cannulation

Painful Extremity/Painful Access Site

Additional Comments:

Patient Demographics, Order, Medication List, Insurance Card

Drop files here or

Max. file size: 300 MB.

Along with this form, please include patient demographics, order, medication list, and insurance card. Upload or Fax to VACI Monterey: 773-881-1214 or VACI Addison 773-549-1717

Improving Delivery and
Outcomes of Vascular Care

We strive for perfection with every patient encounter, and our state-of-the-art facility exists to deliver excellent results. Call us to schedule a personal in-service at our facility or yours.