docOBJECT : REQUEST OF VACANCY OF : Mr /Mrs At the request of
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OBJECT : REQUEST OF VACANCY OF : Mr /Mrs At the request of
CENTRE DE NEPHROLOGIE LES FLEURS 332 avenue Frédéric Mistral Quartier Quiez 83190 OLLIOULES Tél : 04-94-06-87-87 Fax : 04-94-06-87-88 : [email protected] RECIPIENT: FAX : DATE : OBJECT : REQUEST OF VACANCY OF : Mr /Mrs Madam, Sir, At the request of vacancy of your patient for the period : Of in the inclusive. Please find herewith OUR FILE to supplement and to return to us with the requested enclosures: Our duly supplemented file. Certificate of up to date social security of the ALD European chart for patient (be) of the European Union or photocopies provisional certificate of replacement. Serologies (HIV, hepatitises B, C) going back to less than 6 months. Complete biological assessment. Schedule treatment. To reception of the file, and after decision of the nephrologist, a response by telefax will be turned over to you as soon as possible. Sincerely yours The secretariat CENTRE DE NEPHROLOGIE LES FLEURS 332 avenue Frédéric Mistral Quartier Quiez 83190 OLLIOULES Tél : 04-94-06-87-87 / Fax : 04-94-06-87-88 : [email protected] 1 ADMINISTRATIVE FILE IDENTITY OF THE PATIENT NAME : ………………………………………………………………………. First name : …………………………………………………………………….. MAIDEN NAME : …………………………………………………………. Date of birth : ……………./………………/……………………………….. Address : ………………………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………………………………………… Postal code : : .………/…………/…………/…………/……..… CITY : ………………………………………………………………………………. : .………/…………/…………/…………/……..… CENTER NEPHROLOGY : : .………/…………/…………/…………/……..…FAX : …..…/…………/…………/…………/…..…. ADDRESS : …………………………………………………………………………………………………………………………………………………………………… NOBODY OF CONFIDENCE NAME / First name : ………………………………………………………… : …………../……………./……………./………………/………………. NAME / First name : ………………………………………………………… : …………../……………./……………./………………/……………….. SOCIAL RECIPIENT : Ensured United NAME of assured : …………………………………………… Name of the payee : ………………………………………………….. Date of birth of assured so different from the recipient : ………./………../………… N°de Social security : ………………………..…………………………./……… NAME and ADDRESSES organization of sickness insurance : ……………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………… HOLIDAYS ADDRESS holiday place : ………………………………………………………………………………………………………………………………….. holiday place : …………../……………./……………./………………/………………. NAME and of the CONVEYOR chosen : …………………………………………………………………………………………………………………… CENTRE DE NEPHROLOGIE LES FLEURS 332 avenue Frédéric Mistral Quartier Quiez 83190 OLLIOULES Tél : 04-94-06-87-87 / Fax : 04-94-06-87-88 : [email protected] 2 MEDICAL FILE PATIENT NAME : ………………………………………………………………………. First name : …………………………………………………………………………… MAIDEN NAME : ………………………………………………. Date of birth : ……………./………………/…………………………. Group/Rhésus : …………………………………………………………………………………………………………………………………………………….. CORRESPONDENTS NAME OF THE NEPHROLOGUE : ………………………………………….. : …………../……………./……………./………………/……………. NAME OF THE ATTENDING PRACTITIONAR : ………………………… : …………../……………./……………./………………/…………….. NEPHROPATHY Initial nephropathy : ……………………………………………………………………………………………………………………………….. Date from the 1era dialyse : ……………………………………………………………………………………………………………………… Other antecedents : ……………………………………………………………………………………………….………………………………… …………………………………………………………………………………………………………………………………………………………………. ………………………………………………………………………………………………………………………………………………………………… DIALYSE Center UDM Autodialyse A number of meetings : ………………………… DAYS : …………………………………. DURATION : …………………………………………… Generator : ………………………………………………………………. Dialyser : ……………………………………………………………………………. Blood flow : ………………………………………………………………….. Na : ………. K : ……… Ca : ………... CO3H : ………………. Glucose : ………… Dry weight : …………. Kg Average catch of weight : ……………….Kg TA Habituelle : ………./………. Hemodialysis HDF Biofiltration CENTRE DE NEPHROLOGIE LES FLEURS 332 avenue Frédéric Mistral Quartier Quiez 83190 OLLIOULES Tél : 04-94-06-87-87 / Fax : 04-94-06-87-88 : [email protected] 3 MEDICAL FILE (continuation) PATIENT NAME : ………………………………………………………………………. First name : ………………………………………………………………………… MAIDEN NAME : …………………………………………………………. Date of birth : ……………./………………/………………………. ACCESSES VASCULAR Arteriovenous dent Site : Right-hand side Left Biponction Uniponction Needles Catheter Type : ……………………………………………………………………… Cathlons Héparinisation HEPARINISATION Standard heparin : HBPM Continuous Discontinuous Proportion of load : ……………………………………………. Proportion maintenance : …………………………………………………………… SEROLOGIES HBS : Date : ……/……./…….. HBs Ag : ………. HBs Ac : ……………….. Titration : …………. HBcAc : …………… HCV : Date : ……/……./…….. HCV : ………. PCR : ……………….. HIV : Date : ……/……./…….. HIV1 : ………. HIV2 : ……………….. CENTRE DE NEPHROLOGIE LES FLEURS 332 avenue Frédéric Mistral Quartier Quiez 83190 OLLIOULES Tél : 04-94-06-87-87 / Fax : 04-94-06-87-88 : [email protected] 4 MEDICAL FILE (continuation) PATIENT NAME : ………………………………………………………………………. First name : …………………………………………………………………. MAIDEN NAME : ………………………………………………………... Date of birth : ……………./………………/………………… TREATMENTS MEDICAL TREATMENT : (ordinance required) TREATMENT BY EPO : Weekly posology Product : ………………………… Injection per week numbers : …………… Posology by injection : ………. ALLERGY : YES Injection type: IV SC NOT Type : ……………………………………………………………………….. GRAFT Patient registered : oui non Center transplantation : ………………………………………………………….………………………………………………………………. COMMENT …………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………… …………………………………………………………………………………………………………………………………………………………………………………… Date : ……………./………………/………………… Signature and plug of the Néphrologue Doctor CENTRE DE NEPHROLOGIE LES FLEURS 332 avenue Frédéric Mistral Quartier Quiez 83190 OLLIOULES Tél : 04-94-06-87-87 / Fax : 04-94-06-87-88 : [email protected] 5 MEDICAL CERTIFICATE I undersigned, Doctor ................................................. Néphrologue, certifies that: Madam, Miss, Mister ...................................................................................... is usually treated in: AUTODIALYSE CENTER UDM. Fact with …………………………….. …………………………. Signature and plug of the Néphrologue Doctor CENTRE DE NEPHROLOGIE LES FLEURS 332 avenue Frédéric Mistral Quartier Quiez 83190 OLLIOULES Tél : 04-94-06-87-87 / Fax : 04-94-06-87-88 : [email protected] 6 ASSENT OF THE PATIENT I undersigned, Madam, Miss, Mister ......................................................................................, born it: ............./............./.............. 1- declare to have been informed by my doctor nephrologist referent of the conditions under which renal extra purification by hemodialysis in UDM, autodialyse is practised or centers and address the whole of administrative and medical information necessary to the medical establishment. 2- State to have been informed that a doctor is at my disposal for any further information . 3- State to have been informed of the benefit and risks suitable for the extra-renal purification which were explained to me by my nephrologist referent. 4- State to have been informed that the autodialyse functions in the presence of a nurse but without permanent medical presence. 5- Agree to address the examinations serologic going back to less than 6 months (Hepatitises B, C, HIV) prescribed within the framework of my follow-up dialytic before my stay. 6- Accept a possible fold in the event of medical complication or technique towards the service more adapted. 7- Agree to come to all the prescribed meetings and agree to let the nephrologist of the establishment know, as soon as possible, if i am not able to come. 8- State to have been informed of any possible change of /day schedules of dialysis within the course of the stay according to the planning. Signature patient preceded by the mention “read and approved” CENTRE DE NEPHROLOGIE LES FLEURS 332 avenue Frédéric Mistral Quartier Quiez 83190 OLLIOULES Tél : 04-94-06-87-87 / Fax : 04-94-06-87-88 : [email protected] 7
