Consent for Peritoneal Dialysis

Form Template

When kidney disease prevents proper kidney functions, dialysis treatment may be used to sustain life in a patient.

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Peritoneal dialysis is a form of treatment in which a patient receives fluid into the peritoneal membrane inside the abdomen at a rate set by the physician. The Consent for Peritoneal Dialysis form provides users with a comprehensive document of the dialysis treatment plan and the risk involved in undergoing the treatment and records patients informed consent for the procedure.

The form can be easily modified as needed to reflect the patient's needs and obligations accurately. By using the form, patients state their understanding of the entire medical treatment plan of which the dialysis procedure is a part and acknowledge the risk factors like infection, allergic reaction, and life-threatening complications that could result from the peritoneal dialysis treatment. By using this form, a patient and healthcare team can commit to a detailed treatment plan in an effort to adequately care for the health needs of the patient.

At a dialysis facility or dialysis unit treating chronic kidney disease, use this patient care tool to document informed consent prior to clinical peritoneal dialysis therapy. As healthcare professionals, use this app with a patient to inform him or her of potential medical outcomes for this type of dialysis services in your program.

If you need a different consent app, check out this informed consent for hemodialysis form or this consent form for dialysis health status release.

For another dialysis form, check out this dialysis patient consent form.

Features
  • Signature Capture
  • Submission Editing
  • Reference Data
  • Dispatch
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Platforms
  • iPhone
  • iPad
  • Android
  • Windows
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Integrations
  • Quickbooks
  • Salesforce
  • Google Docs
  • Dropbox
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