docTurkish Kidney Foundation Ahmet Ermis Dialysis Center Transient
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Şikayet Transkript
Turkish Kidney Foundation Ahmet Ermis Dialysis Center Transient Transfer Form Patient Name :………………………………………………………………………………………… Date of Birth :………………………………………………….. Age:……………….. Home Address:……………………………………………………………………………………….. Home Phone :………………………………………………………………………………………… Cell Phone :…………………………………………………………………………………………. Referring Physician: …………………………………………………………………………………. Adress While Visiting In Area: …………………………………………………………………….. …………………………………………………………………………………………………………… Local Phone Number : ……………………………………………………………………………….. Desired Dates For Treatment:………………………………………………………………………. Medical History Primary Diagnosis : ………………………………………………………………………………... Secondary Diagnosis : ……………………………………………………………………………….. Any Known Medical Problems: ……………………………………………………………………. ………………………………………………………………………………………………………….. Known Allergies: …………………………………………………………………………………….. Blood Type: …………………………………………………………………………………………….. Date of Last Transfusion: ……………………………………………………………………………. Dialysis Date of Initial Treatment: …………………………………………………………………………… Frequency of Dialysis/Week: ……………………………………………………………………….. Duration of Treatment: ………………………………………………………………………………. Average Blood Flow: ………………………………………………………………………………… Dialyzer: ……………………………………………………………………………………………….
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