Kidney Health Review

If you have been asked to fill in a Kidney Health Review, please submit this form.

If you are human, leave this field blank.

Section

You have been invited by the surgery to complete this form to help the staff review your kidney health. Please complete the following, allowing up to 4 weeks for your review to be completed.

As part of this review process we require you to have your bloods taken, a urine sample checked and vital measurements performed.

Appointments Required:

Health Care Assistant appointment – if possible, please bring a urine sample to this appointment.

Smoking status:

Never Smoked

Ex Smoker

Current Smoker

Please tell us when you are available to have an appointment in the next 3 weeks to have your bloods taken:

If there is anything else you need to share with us regarding your kidney health, please do so below:

One of our clinicians will review the results of your assessment alongside your blood and urine results to determine if any intervention is required. If intervention is required staff will be in touch regarding arranging a follow-up appointment.

In order to complete your review, please choose one of the following two options: *

I have concerns and wish to discuss these in a follow-up appointment

I am happy to complete my review now without further discussion if appropriate

I understand that the practice may need to send me a secure online message about my appointment. I will check my emails.

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Section

Practice Boundary