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Dialysis tours - Confirmation Form
In order to participate to our Dialysis Tours, you must:
 
1) Fill in the following form
2) Click on the "Print Form" button to print the form
3) Sign on the print out
4) Fax the signed print out to Rhapsody Travel
(fax:301 0 9210 997)
 
From: 
Patient's Name:
Date of birth:
(dd/mm/yy)
PRIMARY DESEASE: 
STARTING OF
HAEMODIALYSIS:
Blood
Group		 RH HBsAg Anti-s Anti-e Anti-c Anti-
HCV		 HIV
(I, II)

DIALYSIS CONDITIONS
Duration:
Frequency
(times/week):
Filter:
Vascular Access:
Type of Dialysis:
Conductivity:
Administering
Method:
Dry Weight:
Heparine:
MEDICATION
1) 6)
2) 7)
3) 8)
4) 9)
5) 10)
RECENT CLINICAL TESTS
HT: HB: WDC:
POLYMN: LYMPH: MANO:
EISINOPHILE: ESR: TIBC:
BLOOD SUGAR: UREA: CREATININE:
K/Na: Ca/P: Fe:
FERRITINE: iPTH: AL:
SGOT/SGTP: ALBUM: PLT:
CHOLESTEROLE
/TRIGLYGERIDES		     BILIRUBINEH:
CLINICAL AND OTHER NOTES/OBSERVATIONS
Medical Supervisor of the Haemodialysis Unit:
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 Greece, tel.+30 210 92 42 608, fax. +30 210 9210 997, email: info@rhapsody.gr