Request Dialysis Treatment


You are requesting treatment at:
Lake Dialysis
221 N 1st St
Leesburg, FL 34748-5150

Phone: 1-800-424-6589
Fax: 3523268307

If you need dialysis treatments within the next 7 days, call 1-800-244-0680 and a Guest Services Contact Center Teammate will assist you. Otherwise, if you have more than 7 days to plan, complete this form in its entirety. Please have your destination address and or zip code available before you begin. This information is required in order to find the closest available facility to your destination.

Important note for Peritoneal Dialysis patients: If you're wishing to travel and would like a back-up facility call 1-800-244-0680.

Thank you!

All fields are required unless marked "optional."


Section: 1 of 6
Travel Information
 

MM/DD/YYYY
MM/DD/YYYY
* MM/DD/YYYY
MM/DD/YYYY
Numeric ONLY
* For placement within the next 7 days, please call 1-800-244-0680. This form requires a minimum of 7 days notice.

(optional)
 
 
(optional)
(___)___-____

 
Section: 2 of 6
Your Information
Yes  No  
 
 
Section: 3 of 6
Patient Information

 
(optional)  
 

 
(___)___-____
 
 
Section: 4 of 6
Patient Home Facility Information
 
(___)___-____
(___)___-____

 
 
Section: 5 of 6
Treatment Information
 

 
 
 
: (hours : minutes)

 
 
(optional)
 
Section: 6 of 6
Additional Information
(optional)
 

Feedback

DaVita

© 2004-2014 DaVita HealthCare Partners Inc. All rights reserved. Terms of Use | Privacy of medical information | Web Privacy Policy | Safe Harbor Privacy | FAQs | Site map
This site is for informational purposes only and is not intended to be a substitute for medical advice from a physician.
Please check with a physician if you need a diagnosis and/or for treatments as well as information regarding your specific condition. If you are experiencing urgent medical conditions, call 9-1-1

117