Visitor Request Form

Planning a visit to the Seattle area? If you’re traveling to the greater Puget Sound region, we’ll happily host your treatments at one of our 20 dialysis centers. Please get in touch at least 30 days before you arrive so that we can arrange times and dates that work for you.

Please fill out all fields in this form to request visitor dialysis at Northwest Kidney Centers. If you do not hear back from us within 2 days of your email, please try again or call us at 206-720-8501.

Patient information

Patient name:

Daytime phone:

Email address:

Dialysis dates

Exact dates of dialysis requested:
to

Date of arrival in our area:

Date of departure:

Location

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 206-292-2771. Our privacy notice