Freeport Dialysis Online Appointment Request

VISITING PATIENTS TREATMENT REQUEST FORM

KIDNEY CENTRE FREEPORT
The Kidney Centre is pleased to welcome you and assure you that we are equipped to provide quality service while you enjoy your time in the Bahamas.

All our facilities provide the necessary features for your comfort and convenience. Highly skilled nursing staff operate state-of-the-art equipment in formaldehyde free environment. We make every effort to accommodate the dialysis preference of each patient.

Here are some important information for you to know:

Duration of Dialysis Treatment: Three (3) hours minimum.

Cost of Dialysis Treatment: $627.00 (USD) per treatment (includes 10% local value added tax).

Business Office Hours: 9:00 am to 5:00 pm, Monday to Friday (Closed on Holidays).

Cancellations: For a full refund, prospective clients must give the centre seventy-two (72) hours notice.

If you are scheduled for dialysis on a Saturday or holiday, payment in full is required before your treatment. A credit authorization form will be provided for your convenience. On the day of your appointment, please bring all insurance forms that may be required by your insurance company for reimbursement. We DO NOT accept AMEX Cards, Medicare, or Medicaid insurance. If using any other medical insurance, please provide insurance information when returning forms. Please note, it can take up to seven (7) business days for us to receive a response from your insurance provider.
PATIENT REQUEST FORM

To be completed in FULL.
Patient Information

(This section can be completed by a social worker on behalf of a patient.)
Are you requesting on behalf of a patient?*

YesNo
Your Name.

First NameLast Name
Your Email.
example@example.com
Your Phone Contact
Your Center's Name
Your Center's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a NEW patient to the Kidney Centre?*

Yes, I am a NEW patient.No, I am an RETURNING patient.
Patients Full Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of birth

DayMonthYear
Sex

MaleFemalePrefer not to say
Marital Status

SingleMarried
Home Phone *

Area CodePhone Number
Mobile Number

Area CodePhone Number
Work Number

Area CodePhone Number
Your E-mail Address
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Primary Physician
Name of Home Dialysis Centre.
Address of Home Dialysis Centre.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Next of Kin

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Email
example@example.com
Are you using private health insurance? If so, please provide insurance details.

YesNoOther
Name of Insurance Provider
Insurance I.D number
Please attach copy of insurance card.

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Treatment dates requesting.

Please select the date and time. If you are requiring more than 3 treatments, please indicate in the box provided.
Which centre are you requesting treatment?
How many treatments are you requesting?
Are you requesting additional treatment(s) at one of our other locations? If yes please select.
1st Treatment Date requesting.

MonthDayYearHourMinutesAM/PM Option
2nd Treatment Date requesting.

MonthDayYearHourMinutesAM/PM Option
3rd Treatment Date requesting.

MonthDayYearHourMinutesAM/PM Option
Will you require more than 3 treatments? If so, please indicate additional dates.
MEDICAL INFORMATION
It is important that your medical documents are received and reviewed three (3) weeks prior to your requested treatment date. To ensure your treatment chair is reserved, please return the following documents as soon as possible:
- Your center's patient transfer form
- Last (3) dialysis flow sheets
- Current dialysis orders
- Recent history and physical (within the past 12 months)
- Chest X-ray report (within the past 12 months)
- ECG report (within the past 12 months)
- Hepatitis B panel (within the past 30 days)
- Lab reports inclusive of MRSA nasal swabs, Hepatitis C (within the past 30 days)
- HIV Test (optional)
- Current medication list
- Vaccination record
Please upload scanned copies of documents.

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Additional Upload

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Additional Upload

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IMPORTANT: You will be contacted by a medical representative to confirm your final appointment date and time. Your request is not complete without a final confirmation.
Disclaimer: Although we strive to accommodate your preferred appointment dates and time, we cannot make any guarantees due to a number of conditions, including, but not limited to: business hours of operation, staffing, equipment, availability, and holidays. Please allow us up to 48-hours to respond to your appointment request. If you are requesting an emergency treatment, we ask that you please call us to help expedite your appointment request:

In Abaco

Nurse Peatra Burrows
Telephone: (242)367-3310

Mobile: (242)357-6703
Email: peatra.burrows@kidneycentrebahamas.com

In Grand Bahama

Mrs. Jenny Laing
Telephone: (242)352-7146
Email: Jenny.Laing@kidneycentrebahamas.com
Fax: (242)352-9087
Mobile: (242)727-7508

In Nassau

Ms. Lavette Glinton
Telephone: (242)322-6952
Email: Lavette.Glinton@kidneycentrebahamas.com
Fax: (242)325-3259
Mobile: (242)818-9030
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VISITING PATIENTS TREATMENT REQUEST FORM

PATIENT REQUEST FORM

Patient Information

Treatment dates requesting.

MEDICAL INFORMATION