Travel Worksheet
Complete this information before you call another center asking for dialysis space, and provide this information when you call:
- Dates of dialysis needed (give exact dates):
____________________________________________________ - Time of day you wish to dialyze (be flexible).
____________________________________________________ - Date and time you will arrive in their area:
____________________________________________________ - Date and time you are leaving their area:
____________________________________________________ - Contact information for your current dialysis unit:
Contact name __________________
Unit Phone number_________________
Unit Fax number___________________ - Address where you will be staying when in their area:
____________________________________________________
____________________________________________________
Contact your current dialysis unit with the following information:
- Person you spoke with at the dialysis unit that has space
____________________________________________________ - Phone number _____________________
- Fax number _______________________
- Name and address of dialysis unit that has space:
____________________________________________________
____________________________________________________
____________________________________________________ - Last date you will need to dialyze before travel:
____________________________________________________ - Date you will first need dialysis when you return:
____________________________________________________ - Actual dates of visitor dialysis scheduled:
____________________________________________________ - Will the dialysis unit be faxing paperwork?: yes/no
Once your current dialysis facility has the above information, they will work on getting your medical records and assisting you in meeting the specific requirements of the dialysis facility you are requesting.