REFERRAL FOR LONG-TERM RENAL FOLLOW-UP FOR PATIENTS RECEIVING RENAL REPLACEMENT THERAPY FOR AKI ON PICU Please fill in the details as requested and FAX to number below – this form acts as the referral letter to the Paediatric Nephrologists. Patient name /dob/ address (affix hospital identity label) Phone No Type of renal replacement therapy and dates of therapy CVVH:………………………………………………………………………………………… PD: …………………………………………………………………………………………… Intermittant HD: …………………………………………………………………………… Reason for RRT (tick all that apply) Electrolyte disturbance Fluid removal Toxin removal Metabolic condition Please do NOT book investigations. Paediatric Nephrologist will do this. Referring Doctor: Name: …………………………… Designation: ……………………….. Date: ……………………………. Hospital: …………………………………………….. Please send form together with a copy of the patient’s discharge summary to Kelly Gillingham Renal Assistant to Paediatric Renal Team, E17 Children’s Renal & Urology Unit, QMC Campus. (Phone ext: 61414, fax 0115 9709410; internal 61410) Tracking for notes: Q-PRUSEC