Outpatient Dialysis Treatment Consent

# Outpatient Dialysis Treatment Consent **Dialysis Facility:** ___________ **Facility Address:** ___________ **Attending Nephrologist:** ___________, MD, NPI ___________ **Patient Name:** ___________ **Date of Birth:** ___________ **Medicare/Medicaid Number (ESRD):** ___________ **Date of Consent:** ___________ --- ## 1. Diagnosis and Indication for Dialysis The Patient has been diagnosed with: ___________. The Patient's kidneys are no longer functioning adequately to sustain life without renal replacement therapy. Dialysis is recommended to remove waste products, excess fluid, and electrolytes from the blood, functions that the Patient's kidneys can no longer perform sufficiently. --- ## 2. Type of Dialysis Prescribed **Modality:** ___________ **Prescribed treatment schedule:** ___________ **Target session length:** ___________ **Prescribed dialysate and blood flow parameters:** ___________ --- ## 3. Description of the Procedure