Union Hospital
Haemodialysis Treatment Request for Tourist

        1. Patient's Particulars
   
  * Patient's name:  
  * Sex: Male Female  
  * Age:  
  * Address:
   
   
  * Tel:  
  Fax:  
  * E-mail  
  * Medical Diagnosis:
     
        2. Dialysis Regime in Our Centre
     
  * Arrival date: (Day) (Month) (Year)
  * Departure date: (Day) (Month) (Year)
  * Date of first treatment: (Day) (Month) (Year)
  * Date of last treatment: (Day) (Month) (Year)
  * Session per week:
  * Hours per session:
  * Type of Dialyzer
  Vascular Access Left side
  Blood Flow Rate ml/min
  Dislysate Flow Rate ml/min
  * Dry Weight kg
  Settings:
Bicarbonate mmol/L
Na mmol/L
Calcium mmol/L
  * Anti-coagulant
Heparin LMWH
* Loading Dose unit
* Maintenance Dose unit/hour
     
        3. Valid Laboratory Data (with six month)
     
 

* Compulsory fill-in items, please attach the relevant laboratory documents.

*HbsAg Reactive Non-reactive
*HbsAb Reactive Non-reactive
*HBc Total AB Reactive Non-reactive
*Anti-HCV Antibody Reactive Non-reactive
*Anti-HIV Reactive Non-reactive
*MRSA (Nasal) Positive Negative
Glucose mmol/L
Haemoglobin g/dL
Serum Sodium mmol/L
Serum Urea mmol/L
Serum Creatinine mmol/L
Serum Potassium mmol/L
Serum ALT U/L
Serum Phosphate mmol/L
Serum Calcium mmol/L

 

Doctor Signature : ____________________

 

Please fax or E-mail to our centre
Fax: (852)-26012321
Tel : (852)-26083212
E-mail: renal@union.org
     
        4. Local Contact Person (if applicable)
   
 
  Name  Relationship Telephone
1.
2.
       
       
* Verification Code