Form – Quavitae Rive Droite

Step 1 of 5 – Identity

This field is for validation purposes and should be left unchanged.

Patient information

Full name*

First Last

Date of birth*

Email*

Phone*

Emergency contact phone*

Home address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Section to be completed by your usual dialysis center

The information below (dialysis modality, vascular access, anticoagulation, technical parameters) comes from the patient’s current Dialysis protocol. It must be completed by your usual dialysis center — physician, specialist nurse, or administrative staff with the up-to-date protocol.

Are you the patient and do not have this information to hand? Click “Save and forward” at the bottom of the page and enter the email address of your usual dialysis center. They will receive a unique link to complete this section, then send it back to you so you can attach your documents (page 5) and submit the request to the center.
Are you the dialysis center? Complete the section below, then click “Save and forward” and enter the patient’s email address. They will then be able to finalize the request by attaching the required documents and submitting it.

Dialysis protocol — General parameters

Dialysis modality*

HDF

Treatment duration*

Vascular access*

Fistula

Catheter

Single-needle

Catheter — A (ml)

Catheter — V (ml)

Lock solution

Location*

Needles*

Blood flow rate*

Dry weight*

Max UF rate*

Filter / Dialyzer*

Notes (protocol)

Dialysate composition

Bicarbonate (mmol/l)*

K (mmol/l)*

Calcium (mmol/l)*

1.25

1.5

Glucose (mmol/l)*

Na (mmol/l)*

Anticoagulation

Heparin (type)*

Heparin — initial dose (IU)

Heparin — continuous dose (IU/h)

Initial LMWH

Blood pressure

Blood pressure — before dialysis*

Blood pressure — after dialysis*

Additional information

Complications during the session

General notes

Spoken language*

Mobility

Diet

Medical validation

Document completed on*

Place (at)*

Name of signing physician*

Dialysis center / Hospital / Practice*

Signature*

Draw your signature with your finger (mobile) or mouse (computer).

Holiday dialysis request