This Admission Intake form is for use for by physicians, social workers, or case managers looking to place a patient in need of in-center dialysis to a Rogosin Dialysis Center.
If you are a patient looking for a nephrologist, please click HERE.
All areas shaded in gray must be completed on the form for quick admission.
Patient Care and Prior to First Treatment information sections are helpful but can be provided after receiving treatment.
Fax (or phone) the completed form along with supporting documentation to the preferred facility.
*If you don’t know the center you wish to refer, use the quick reference map for requested facility.