Patient Request Form
for free support
If you would like to receive a Dialysis Support Bag, please provide all the requested information on the form and then click Submit at the bottom.
For Dialysis Centers
If you are an employee of a dialysis center and would like to receive support bags for your clients, please contact us. We enjoy working with the centers as it makes our reach larger while decreasing costs to serve more patients. We are currently looking to pilot a mental wellness program with a clinic or 2 and would love to speak to you about the opportunity. You can reach us at dialysissupport@esrd-patient-support.org