Dialysis Unit Information Form Dialysis Unit Information Form Name of Patient * Date of Travel * Does this patient use a wheelchair or mobility scooter? * Yes No Does this patient use a walking device? ie rollator, walking stick etc * Yes No The dialysis unit onboard Ambience is NOT wheelchair accessible and can be a distance of 6 metres to walk to the furthest bed. Can this patient walk to the bed WITHOUT assistance? * Yes No If you have answered NO to the above question, please advise if the patient is travelling with someone who will assist them to the bed, and on and off the bed if required in the dialysis unit? * Yes No The patient does not require assistance to the bed or on and off the bed Patient's MRSA status * Negative Positive Patient's Hepatitis B status * Negative Positive Patient's Hepatitis C status * Negative Positive Patient's HIV status * Negative Positive Is this patient currently in treatment for VRE? * Yes No Name of Holiday Dialysis Co-ordinator * Holiday Dialysis Co-ordinator Telephone Number * Holiday Dialysis Co-ordinator Email Address * Dialysis Unit Email Address - Please ensure this is a different email address to the Holiday Dialysis Co-ordinator * Patient's Consultant / Nephrologist Email Address * Dialysis Unit Name and Postal Address including Postcode * Dialysis Unit Telephone Number * If you are human, leave this field blank. Submit Start Over Δ
