azura surgery center - long beach

Specializing in Dialysis Access Management & Vascular Care

+1 (562) 888-8961

info@southerncaliforniavascular.com
16506 Lakewood Blvd Suite 200,
Bellflower, CA 90706

Monday - Saturday 7:00 - 4:00

OPEN Saturdays - Sunday - CLOSED

+1 (562) 888-8961

info@southerncaliforniavascular.com

16506 Lakewood Blvd Suite 200

Bellflower, CA 90706

REFER A PATIENT - Click here to refer a patient to Our Surgery - Long Beach
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PATIENT SCHEDULING FORM: ESRD Dialysis Access

Azura Long Beach Dialysis Access ESRD Patient Scheduling Form

MM slash DD slash YYYY
MM slash DD slash YYYY
Mon/Wed/Fri
Tues/Thurs/Sat

Access Procedure

NOTE: In compliance with the Universal Protocol for Wrong Site Surgery, all areas highlighted below must be completed in full by the referrer. (If nursing home, please indicate.)
Access Type
Location (Right/Left)
Location
Procedure Order
Indication (Access Procedure)
*select all that apply

Catheter Procedure

Site:
Site:
Site:
Desired Procedure:
Indication (Catheter Procedure)
(select all that apply)

Clinical Information

X-Ray Contrast Allergy
Diabetic
Latex Allergy
Any Anticoagulants?

Transportation Needs

Is the patient able to provide or arrange his/her own transportation?
Patient condition
Post-procedure destination:

Dialysis Clinic - Please complete the following information:

Competent to sign consent:

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