Dialysis Center Patient Intake Form

The Dialysis Center Patient Intake Form is a comprehensive clinical onboarding document designed for facilities that provide hemodialysis and peritoneal dialysis treatments to patients with end-stage renal disease (ESRD) and advanced chronic kidney disease (CKD). Dialysis patients require highly individualized treatment protocols based on their kidney function history, vascular access status, fluid balance, and complex comorbidity profiles. This intake form captures the detailed medical, treatment, and lifestyle information that nephrologists and dialysis care teams need to establish safe, effective, and personalized treatment plans for each new patient entering their program.

The form collects a thorough clinical history specific to renal care. It documents the stage and cause of kidney disease, the date dialysis was initiated, the current dialysis modality (in-center hemodialysis, home hemodialysis, or peritoneal dialysis), and the patient's treatment schedule. Vascular access information records the access type (arteriovenous fistula, graft, or central venous catheter), its anatomical location, and any history of access complications such as thrombosis, stenosis, or infection. The form captures current fluid and dietary restrictions including sodium, potassium, phosphorus, and protein limits prescribed by the nephrology team. A comprehensive medication list section documents renal-specific drugs including erythropoiesis-stimulating agents, phosphate binders, vitamin D analogs, and antihypertensive medications. Additional sections record transplant history and waitlist status, comorbid conditions such as diabetes, hypertension, and congestive heart failure, and laboratory values including most recent creatinine, BUN, hemoglobin, and Kt/V adequacy measurements.

This form is used by outpatient dialysis centers, hospital-based renal units, nephrology specialty practices, home dialysis programs, and acute dialysis services. It supports compliance with the Centers for Medicare and Medicaid Services (CMS) Conditions for Coverage for ESRD facilities, which mandate comprehensive patient assessments at admission and require individualized care plans developed by an interdisciplinary team. The form also facilitates continuity of care when patients transfer between dialysis facilities, are hospitalized, or travel and require guest dialysis services at another center. By capturing complete baseline clinical data in a structured format, the intake form enables care teams to identify contraindications, prevent adverse events during treatment, and maintain the detailed patient records required for CMS surveys and quality reporting programs such as the ESRD Quality Incentive Program (QIP).