Fast Track UKC Dialysis Treatment Request

For Dialysis Treatment within 24 hours, please call (954) 770- 6540 otherwise, please complete this form in its entirety.

Arrival Date in Florida:
Departure Date:
First Requested Treatment Date:
Last Treatment Date:
Total Number of Treatments:
Dialyis Center Location:	Fort Lauderdale Boyton Beach / Palm Beach Margate / Coral Springs Davie Pembroke Pines / Miramar
PATIENT INFORMATION
Patient's First Name:
Patient's Middle Initial:
Patient's Last Name:
Patient's Date of Birth:
Patient's Street Address:
Patient's City:
Patient's State:	> Select One < Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Patient's Zip Code:
Patient's Phone Number:
Patient's Email (optional):
Treatment Schedule:	> Select One < Mon, Wed, Fri Tues, Thurs, Sat
Is Your Treatment Schedule Flexible?	Yes No
Does Patient Require Isolation?	Yes No
Length of Treatment:	1 2 3 4 : 00 15 30 45 (hh:mm)
Primary Insurance Type:	> Select One < Medicare Medicaid Private PPO Private HMO
Name of Primary Insurance Company:
Name of Secondary Insurance Company: