Dialysis Care Form

Basic Information

I am a :

First Name *

Last Name

Contact Number *

Email Id *

Prefered method of contact

Are you currently on dialysis? *

Yes – Haemodialysis

Yes – Peritoneal Dialysis

No – Exploring Options

How many times per week? *

1-3 times a month

1- 3 times a week

More than 3 times a week

Preferred time for sessions *

Morning (9 AM - 12 PM)

Afternoon (12 PM - 3 PM)

Evening (3 PM - 6 PM)

Flexible

Medical Background

Do you have any of the followings ? *

Diabetes type 1

Diabetes type 2

High blood pressure

Heart condition

Hepatitis B/C

HIV

Others

If others,

Are you currently on any medications?

Yes

No

Value-Added Services (optional), I'm interested in :

Transportation Support (Ambulance, Grab, Jom MakCik)

VIP/Private Room

Wheelchair Accessibility

Personalised Plan

Further patient Info

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