Request Dialysis Treatment

You are requesting treatment at:

South County At Home
4145 Union Rd
Saint Louis, MO 63129-1064

Phone: 1-800-424-6589
Fax: (314) 894-3879

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."

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Travel Information


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



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Your Information

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Patient Information


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Patient Home Facility Information


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Treatment Information


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Additional Information