Get Nc Vascular Access Referral Form 2019-2025

This guide will provide you with step-by-step instructions to accurately complete the NC Vascular Access Referral Form online. By following these instructions, you can ensure that all necessary information is submitted for your vascular access needs.

Follow the steps to complete the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter today’s date in the designated field at the top of the form. This identifies when the referral is being submitted.
3. Input the desired procedure date and patient name. Ensure that all names are spelled correctly to avoid confusion.
4. Fill in the patient’s date of birth and UNC medical record number if applicable. This information is crucial for patient identification.
5. Include the patient’s contact information: phone number and address. This will facilitate communication and scheduling.
6. Specify the nursing or rehabilitation facility, if applicable, along with their respective phone number.
7. List an emergency contact name and their phone number for any unforeseen situations that may arise.
8. Verify that you have all required documents noted in the form, such as the completed referral, signed order, demographic sheet, medication list, etc., to be faxed to Carolina Vascular Access for an appointment.
9. Provide the ordering provider's signature and the nephrologist's name to validate the referral.
10. Indicate whether the patient has the capability to dialyze. This field is essential for assessing the patient’s condition.
11. Select the type of vascular access (graft, fistula, etc.) and provide the location and procedure details.
12. Document any indications leading to the referral. This helps in understanding the context of the vascular access needs.
13. If the patient has allergies, provide details including the type of allergy and any reactions experienced.
14. Indicate how the patient will be transported to the dialysis center, which is critical for planning their visit.
15. Finally, review all entries for accuracy, then save your changes before downloading, printing, or sharing the finalized form.

Complete the NC Vascular Access Referral Form online today to ensure timely processing of your referral.