Order form

Indication:
---Acute renal failureChemotherapyChronic renal failureParenteral therapy

Type of intervention desired:
---New central venous catheter insertionNew peritoneal dialysis catheter insertionCatheter exchangeCatheter removalOther

Type of Central venous catheter insertion
---TunneledNon-tunneled

Indication:
---Access surveillanceAneurysmСlotted accessDifficult сannulationDiminished flow rateHigh flow rateHigh venous pressureInfiltrationLimb swellingNon-maturing fistulaPainPlanning for a surgically- created fistulaPoor labsProlonged bleedingRecirculationSteal syndromeOther

Type of access:
---AV fistulaAV graftBilateral upper extremity venogram

Location of access:
---Left armLeft forearmLeft thighRight armRight forearmRight thighOther

Desired intervention:
---Duplex ultrasonographyFistulogram/graftogramThrombectomyVenogramOther

 Biopsy (please specify organ)

 Drainage of body fluid by catheter insertion (please specify location and side)

 Insertion of a central venous catheter with a subcutaneous port. Insertion of a central venous catheter without a subcutaneous port. Insertion of peritoneal dialysis catheter.  Joint aspiration and/or injection (please specify which joint)

 Management of chronic venous hypertension Management of pelvic congestion syndrome Management of peripheral arterial disease Management of symptomatic uterine fibroids  Management of vertebral compression fracture (specify level)

 Nephrostomy catheter insertion (please specify laterality)

 Radiofrequency ablation of a tumor (please specify location and type)

 Other

 Abdominal aortic ultrasound Abdominal ultrasound Arterial Doppler ultrasound of the extremities (please specify type and side)

 Bladder ultrasound Breast ultrasound (please specify type and side)

 Carotid ultrasound Gallbladder ultrasound Musculoskeletal ultrasound (please specify type and side)

 Obstetric ultrasound (please specify trimester)

 Pelvic ultrasound Prostate ultrasound Renal ultrasound Scrotal ultrasound Thyroid ultrasound Venous Doppler ultrasound of the extremities (please specify type and side)

 Other