PHILIPPINE, RE,NAL T}ISEASE REGISTRY (PRI}R)

National Epidemiology Ce:nter - Departrnent of l{ealth

Renal Disease Control Program - National Kidnsy and Transplant Institute
Rm. C-06,3rd Floor Main Building. East Avenue. Quezon City
Telephone Nos.: {02) 925-3679: 981-0300 local 31 I I
Teletax No.: (02) 925-3678

}{OTIFICATION SLIP

NAME OF DIALYSIS UNIT:

MANAGED/OPERATED BY:

CLASSIFICATION
FS - Free Standing t]GHO - Governrnent, Hospital Owned
t]GHB - Government, Hospital Based nPHO - Private, Hospital Owned
nPHB - Private, Hospital Based

FACILITIES
n Peritoneal
Hemod ia lysis n Kidney Transplant

l Dialysis t] Kidney Biopsy

ADDRESS OF UNIT
Region: P rovince : Municipality:
Barangay: Street: Build ing #:

Telephone #: Fax #:

Email Address:

MEDICAL DIRECTOR:
HEAD NEPHROLOGIST:

LIST OF AFFILIATED NEPHROLOGISTS

DIALYSIS UN IT COORD!NATOR:

DATE OF START OPERATION:

DOH LICENSE #: DATE ISSUED:

PHILHEALTH #: DATE ISSUED:

SUBMITTED BY:

DESIGNATION:
{ Regionsl Coordinstar/Assf. Reg ion sl Coord i nstor/

Medicol DirectarlNe phrolagist/Dialysrs Unff Coardi nator)