Lower Manhattan Dialysis Center
Travel Dialysis Application Form

44 YEAR LEADER IN SAFE DIALYSIS
WE HAVE A PROVEN RECORD OF CLINICAL EXCELLENCE & PATIENT SURVIVAL
HIGH QUALITY INDIVIDUALIZED MEDICAL CARE

323 EAST 34TH ST. 
NEW YORK, NY 10016

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Mr./ Ms.:Age :

Address :

City :State : Zip Code :

Country :Telephone # :

E-Mail :

Intended Destination:Days of Stay:

Date of Last Session in your usual Center:

Dates of Dialysis Being Requested :

Time of Day Dialysis Being Requested :

Number of Hours :

Please enter any questions or comments, 
Ms. Mercurius will reply as soon as possible :


 
 
 

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Lower Manhattan Dialysis Center
323 East 34th St. 
New York, NY 10016
 
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      E-Mail:  Administrator@LowerManhattanDialysis.com
 

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