Kidney Care Bermuda Visitor Intake Form

Bermuda Home Dialysis Services

Visitor Intake Form
We will contact you via the email you provided within 5 business days. Please note that your intake documentation and payment must be received no less than four (4) weeks prior to your visit to ensure a dialysis slot can be reserved and to avoid an “expedited fee” of $50.
Patient Name
DOB
Email Address
example@example.com
Name and address of your Home Clinic
Clinic Phone Number
Contact Person (RN or SW)
Type of Dialysis you are on
First Day of Dialysis
Any recent dialysis issues?
Date of Arrival

MonthDayYear
Date
Date of Departure

MonthDayYear
Date
Arrival Flight
Name of Hotel
Name on Reservation
What is your address while in Bermuda?
Telephone
Name of Person Receiving Supplies
Patient Contact Information in Bermuda
Should be Empty: