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*
Date of Birth*

MonthDayYear
Date
Email Address*
example@example.com
Name and Address of your Home Clinic*
Clinic Phone Number*
Contact Person (RN or SW)*
Contact Person Email Address*
example@example.com
Type of Dialysis you are on*
Any recent dialysis issues?
Date of Arrival in Bermuda*

MonthDayYear
Date
Date of Departure*

MonthDayYear
Date
Arrival Flight - Airline and Flight Number
Name of Hotel / Guest House
Name of Cruise Ship and Berth Location
Name on Reservation
What is your address while in Bermuda?
Telephone Number
Name of Person Receiving Supplies
Patient Contact Information in Bermuda
First Day of Dialysis in Bermuda (requested)*

MonthDayYear
Date
Last Treatment Date Prior to Arrival in Bermuda - Please note that we don’t accept patients with a window between treatments greater than two (2) days.*

MonthDayYear
Date
How did you hear about us?
Should be Empty:

Bermuda Home Dialysis Services