PRINEd Physician Referral Form Nephrologist*PrinceAliTepedinoCohenSedkiBhasinDilmetinGordon-DubsWengerLaxIoannouChunLibermanFriedmannErlichSwartzPinkhasovRubelOTHERPatient Name*First and Last NameWhat would you like to do?*Refer patient: PRINEdReport patient: DialysisReport patient: TransplantDIALYSIS ReportingNot yet on dialysis but has been referred for accessNot yet on dialysis but has accessStarted In-center HDStarted Home dialysisWas it an optimal ESRD Start?Yes, Initial dialysis was at home (HHD or PD)Yes, Initial dialysis was at outpt center via AVFYes, initial dialysis was at outpt center via AVGNo, initial dialysis was in hospital TRANSPLANT ReportingMy patient has been listedMy patient received a transplantWhich transplant center?Which PRINEd Class?*BASICSESRD CHOICESBOTHWhat would you predict your patient's PAM Activation Level to be?Level 1 (Disengaged and Overwhelmed)Level 2 (Becoming Aware but still Struggling)Level 3 (Taking Action and Gaining Control)Level 4 (Maintaining Behaviors and Pushing Further)Last eGFR or CrCl (provide value and date please)Estimated time to dialysis*1 month or less1-3 months3-6 monthsmore than 6 monthsDo you have a Dialysis preference for this patient?In-center HemodialysisHome HemodialysisPeritoneal DialysisEither home modalityNo preferenceDoes patient have access for dialysis?*YesNoWhat type of access? Who placed access? When was it done?Do you have a preference as to what type of access and who you would like to send patient to get access?Is patient a Transplant candidate?*YesNoMaybeWhat is your preferred Transplant Center?NorthwellNYU / WinthropMt. SinaiStony BrookRogosin (Cornell)ColumbiaAny comments or things you think we should know about your patient before we contact him/her?