Union Hospital
Haemodialysis Treatment Request for Tourist

1. Patient's Particulars
Patient's name:
Gender: 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 Right 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 results
(within recent three month of proposed HD date)
 
* 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) 2601 2321
Tel: (852) 2608 3212
E-mail: renal@union.org
 
4. Local Contact Person (if applicable)
 
  Name Relationship Telephone
1.
2.
 
＊　＊　＊
 

Dear Sir/Madam,

With reference to your enquiry regarding the haemodialysis services in our centre, we are pleased to provide the following information for your reference.

1. Rates of Treatments
  • Using A-V fistula: HK$2,840 per treatment
  • Using HD catheter: HK$3,220 per treatment

(The above rates include the conventional heparin, dialyzer, basic consumables for dialysis only. Doctor fees is NOT included.)

Remarks

  • HK$160 administration fee will be charged on the first day of treatment for handling application documents
  • HK$110 discount per treatment if the visitor provides a single use dialyzer
2. Booking

Please fill in the attached Tourist Application Form, together with the following documents and return them to us by fax or e-mail (see below) for advance booking. You should also present the original copy of those documents on the first day of treatment for verification.

  • HbsAg, HbsAb, Anti-Hbc, HCV, HIV status report and nasal swab for MRSA status (checked within recent 3 months of the proposed haemodialysis date)
  • Medical referral letter, and
  • Last two haemodialysis records

All medical records and reports must be in either English or Chinese.
3. Please bring along your passport or identity document on the first day of treatment for registration.
4. Please bring along your own oral medications, if any.
5. For medication safety, no private drugs of the visitor are accepted for intravenous infusion, intravenous, intramuscular or subcutaneous injection. Only medicine supplied by the Union Hospital Pharmacy will be allowed for such purposes. You may contact our staff regarding the price of drugs.
6. Union Hospital reserves the right to amend any information without prior notification.
Should you have any queries, please feel free to contact us via fax or e-mail.
 
Our E-mail : renal@union.org
Address : Renal Dialysis Centre,
1/F, Main Building, Union Hospital,
18 Fu Kin Street, Tai Wai Shatin,
New Territories, Hong Kong
Website : http://www.union.org
Tel : (852) 2608 3212
Fax : (852) 2601 2321
Office hours : 7am-8pm on Mondays to Saturdays and public holidays, close on Sundays
 
Best regards,

Renal Dialysis Centre
Union Hospital