Visitor Request Form

Please fill out all fields in this form to request visitor dialysis at Northwest Kidney Centers.

Patient Information
Patient Name:
Daytime phone:
Email:
Dialysis Dates
Exact dates of dialysis requested:
Date of arrival in our area:
Date of departure:
Location Information
Location requested:
City where you will be staying (if Seattle, provide address or ZIP code):
Your Current Dialysis Provider
Dialysis facility name:
Dialysis contact name:
City/State:
Dialysis phone:
Dialysis fax:
Additional Information
Special dialysis or scheduling requirements:

CONFIDENTIALITY NOTICE: Northwest Kidney Centers' website is reasonably secure but is not encrypted. If you are not comfortable sending this information electronically, you may phone us at 206-365-6656.

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Northwest Kidney Centers keeps people in the Seattle area alive with dialysis care, educates the public about kidney health, and collaborates with UW Medicine in the Kidney Research Institute. We are one of very few community-based, nonprofit dialysis providers in the country. Founded in 1962, ours was the first out-of-hospital dialysis program in the world and it is still a model in the field.