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Home
About us
Who We are
Executive Leadership Team
Physician Leadership Team
Services
Care Team
Locations
Office Locations
Kidney Specialists Surgical Center
Hospital Affiliations
Dialysis Units Affiliations
Patient Resources
View Patient Resources Guide
Inner Menu
New Patients
New Patient Registration
Referring Physicians
Insurance
Patient Forms
Transplant
Existing Patients
Patient Portal
Obtain Medical Records
Online Bill Payment
Care Navigation
PRESCRIPTION REFILL REQUEST
More Information
Patient Education
Telemedicine
Kidney Disease Education
Top 10 Q & A
Privacy Practices
COVID-19 Information
Referring Physicians
Schedule Your Consultation
Book Now
CALL US: 702-877-1887
Vein Mapping Referral
"
*
" indicates required fields
Patient Information
Patient Name
*
Date Of Birth
*
MM slash DD slash YYYY
SSN
*
Address
*
Phone
*
Primary Insurance
Policy Number
Resident of Nursing Home?
Yes
No
Patient located at a SNF?
Yes
No
Patient Oxygen? ( If yes, the patient must bring their O2 Tank with them)
Yes
No
Patient on a stretcher? ( If yes, the patient’s driver must stay for the entire visit)
Yes
No
Competent to Sign?
Yes
No
Patient Primary Language
Previous Surgeon
Preferred Vascular Surgeon
Indicate the existing catheter/graft/fistula
Catheter Location
RIGHT CHEST
LEFT CHEST
RIGHT GROIN
LEFT GROIN
PD CATHETER
Graft/Fistula Failure
RIGHT FISTULA
RIGHT GRAFT
LEFT FISTULA
LEFT GRAFT
Dialysis Center
HD Days
Select an option
First Choice
Second Choice
Third Choice
Shift time
Scheduled by ((Verbal order-RN) (Print name & credentials)
Nephrologist
Please upload demographics, ID, Insurance Card, and records here
File
Max upload size: 8 MB
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Select files
Accepted file types: jpg, gif, png, pdf, svg, Max. file size: 8 MB.
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