Emergency Department

Emergency Department (ED) Diversion Assistance Request

Please complete the below form to assist with placement for a DaVita dialysis patient who has come to your Emergency Department during an emergency event. You will be contacted shortly with information on where to direct our patient.

All fields required.

Patient Name:

Patient Date of Birth:

Patient Home Address:

Home Clinic:

Hospital Name:

Discharge Planner Name:

Discharge Planner Contact Number:

Discharge Planner Email:

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