ReMend PATIENT REFERRAL FORM

Patient Referral Form

Connecting someone to our peer-to-peer program? You're awesome!
Please complete the following HIPPA-compliant form.
Who is referring the patient? (Social Worker, Nurse, Dietician, Physician etc.)*
Which dialysis facility and location?*
Please indicate which program the patient is interested in participating.*

PEER-TO-PEER MENTORINGONLINE SUPPORT COMMUNITY
Patient Name*
Patient Date of birth*
Patient Gender*

MaleFemale
Patient phone number (mobile or preferred number)*
Patient phone number (additional/landline)
Patient e-mail address
What is the patient's preferred time of day to speak to a ReMend representative?*

AMPM
What is the patient's preferred language? Current available languages are English & Spanish. There is a short wait for Spanish speaking mentees.*

EnglishSpanish
Patient's Nephrologist
Patient Modality?*

In-Center HemodialysisPeritoneal Dialysis - ManualPeritoneal Dialysis - CyclerHome Hemodialysis
What is the patient's interest in contacting ReMend? (Choose as many needed.)*

CopingDietary AdherenceHealthcare CoverageTreatment AdhearnceHospitalizationsHome Dialysis TherapiesMedication AdherenceLiving DonationOther
If "Other", please explain. Feel free to add any helpful information.
Should be Empty:

Patient Referral Form