Lower Manhattan Dialysis Center

Lower Manhattan Dialysis Center
Travel Dialysis Application Form

29 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

Tel: 212-889-1082
Fax: 212-725-3538

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.Torres will reply as soon as possible :

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Lower Manhattan Dialysis Center
323 East 34th St.
New York, NY 10016

                                                        Tel: 212-889-1082
                                                       Fax: 212-725-3538
      E-Mail: Administrator@LowerManhattanDialysis.com