Continuing Care Reasons for Referral Checklist

To facilitate consistent communication, here is a sample checklist that can be sent with the official Continuing Care referral form. Note that this checklist is NOT an official referral form.

This patient has end-stage kidney disease and has chosen Conservative Kidney Management (CKM) including NO dialysis.

Reason(s) for referral (check all that apply):

Goals of Care Designation form signed and in the client's home (y/n)? ___________ Date: ___________

Symptoms (check all that apply):

Patient's general condition:

Family Doctor or Primary Healthcare Provider

Name: ______________________ Date: ___________

Please direct any future correspondence to the patient’s family doctor or primary healthcare provider.

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