Transfer/Endorsement Form
Endorsing Patient To:
Patient's Name :Arcee Ballarta Ocampo asdasd Gender :Male Age : 26 CS :Single
Femoral Catheter
Permanent
Catheter
Internal Jugular
Left
Veinr
AV Fistula Left
AV Graft
Subclavian
Frequency: 0.00
Duration: 2
Dialyzer: 2
1:
2:
3:
Anti-HCV
Anti-HBs
HBsAg
HBeAg
Anti-HBe
Anti-HBc
[ ] I will be the attending
Contact #: PHIC Accreditation No./Validity
nephrologist