Dialysis Center Patient Intake Form

This dialysis center intake form is specifically designed for nephrology practices, outpatient dialysis facilities, and hospital-based renal units managing patients requiring hemodialysis or peritoneal dialysis treatments. The form collects critical information about kidney function history, previous dialysis experience, vascular access sites, current fluid and dietary restrictions, and complications related to chronic kidney disease. It includes sections for documenting comorbid conditions that affect dialysis treatment such as diabetes, hypertension, and cardiovascular disease.

The template streamlines patient onboarding for dialysis centers by gathering essential clinical data including current medications, allergies specific to dialysis treatment, transplant history, and emergency contacts familiar with the patient's renal condition. It enables care teams to assess baseline health status, identify contraindications, and develop individualized treatment plans. The form supports compliance with CMS ESRD regulations and helps ensure continuity of care when patients transfer between dialysis facilities or require hospitalization.