The Royal Artemis Hemodialysis center. Hemodialysis, peritoneal dialysis while travel for holidays.

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Hemodialysis Enquries Form

Date:
Surname:
Name:
DOB:
Age:
Address:
Telephone:
Telefax:
Email:

Period requiring dialysis
From:
To:
Year:
*Hemodialysis details*
Cause of ESRD:
Initiation of H/D:
Hours per week:
Dry weight:
Type of Heparine:
*Dose of Heparine:*
Initial bolus:
Continuous infusion:
Vascular Access
*Please choose method to use*
Single Needle dialysis Two needle dialysis
Blood Flow:
Dialysate:
*Last date checked for*
HIV:
HbSAg:
HCV:
Hemodialysis related problems:
Other health problems:
Medication:

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