The Mermaid Centre for Renal Dialysis 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the PATIENT DATA section. Enter your surname, first name, home address, NHS number, title, date of birth, phone number, mobile number, and postcode. Ensure all details are accurate for seamless processing.
3. Next, provide information about your regular dialysis unit including its name, address, telephone number, and safe fax number. Include the names of your renal consultant and holiday dialysis coordinator along with their email addresses.
4. In the DIALYSIS MEDICATION LIST section, list all medications you will accompany during your holiday dialysis. Fill in the medication name, dose, route, and frequency for each item listed.
5. Complete the HEALTH INFORMATION section by detailing the primary cause of renal failure and any relevant medical history. Include BBV/MRSA clearance test results as required.
6. Fill out DIALYSIS INFORMATION with specifics about access type and comments regarding your treatment plan. Provide details on dialysate composition and average blood pressure readings.
7. In the FINANCE section, indicate who is responsible for payment by providing their name, job title, email address, and signature. Include a purchase order number if applicable.
8. Finally, ensure that both you and the holiday coordinator sign where indicated to confirm understanding of terms and conditions before submitting the form.

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