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Makati Medical Center

Transfer/Endorsement Form
Endorsing Patient To:

Patient's Name :Arcee Ballarta Ocampo asdasd Gender :Male Age : 26 CS :Single

Patient's Contact Number/s :09998841532 Date of Admission:


Person to Notify Incase of Emergency/Relationship/Contact Attending Physician :Arcee01 Ballarta01
Number:09998841532 Ocampo01
Complete Renal Diagnosis : Acute Kidney Injury

Other Diagnosis/Comorbidities :Obstructive Uropathy / Bronchial Asthma,skin cancer

Vascular Access: Access Location: Surgeon: Date Created: Hospital:

Femoral Catheter
Permanent
Catheter
Internal Jugular
Left
Veinr
AV Fistula Left

AV Graft

Subclavian

Hemodialysis Prescription Current Medication List

Frequency: 0.00

Duration: 2

Blood Flow Rate(BFR): 2

Dialysate Flow Rate(DFR): 2

Dry Weight: 2.00

Anticoagulation: Low Molecular Weight Heparin

Dialyzer: 2

Complications/Problems Encountered During Hemodialysis

1:

2:

3:

Hepatitis Profile: Date Taken: Qualitative: Quantitative: Immunization: Date Given:

Anti-HCV

Anti-HBs

HBsAg

HBeAg

Anti-HBe

Anti-HBc
[ ] I will be the attending
Contact #: PHIC Accreditation No./Validity
nephrologist

[ ] Transfer Service to,MD Contact #: PHIC Accreditation No./Validity

Attachments: [ ] Last 3 Hemodialysis Treatment Sheet [ ] Laboratory Flow Sheet/Results

Name and Signature of Referring Nephrologist: