Follow the steps to fill out the NC Vascular Access Referral Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter today's date and the desired procedure date in the corresponding fields.
3. Fill in the patient’s full name, phone number, date of birth, and UNC medical record number if applicable.
4. Provide the patient's home address, emergency contact, and their contact number.
5. Select the preferred dialysis schedule by checking the appropriate boxes (M, Tu, W, Th, F, Sa, Daily).
6. Indicate whether the patient can dialyze by selecting 'Yes' or 'No.'
7. Specify the type of access by checking either 'Graft' or 'Fistula'.
8. Complete the sections related to the last dialysis treatment, surgeon's name, and when the access was placed.
9. Fill out the indications section by checking all applicable boxes.
10. For catheter needs, detail the type, site, and desired procedure in the respective fields.
11. Answer all health screening questions regarding allergies, diabetic status, anticoagulants, and insurance.
12. Indicate if the patient requires a hoyer lift and record transportation arrangements to dialysis.
13. Finally, ensure that the ordering provider's signature field is completed along with the nephrologist's name.
14. Review all completed sections to confirm accuracy, then save changes, download the form, print it, or share it as needed.

Complete your NC Vascular Access Referral Form online today to facilitate a smooth referral process.