UHN MRN The Toronto Western Hospital Liver Centre  6B – Fell Pavilion  399 Bathurst Street  Toronto, ON M5T 2S8 www.torontoliver.ca Francis Family Chair  Dr. Harry Janssen Hepatologists  Dr. Hemant Shah Dr. David .K. Wong  Dr. Jordan Feld  Dr. Angela Cheung Nurse Practitioner Colina Yim  No Preference – 1st Available Hepatologist *We reserve the right to assign staff based on availability or patient’s medical requirements. COMPLETE & FAX BOTH PAGES PLUS TEST REPORTS TO 416-603-6281 Or Referral will be REJECTED  ALL queries to 416-603-5914 -- Option 2 (not to physician offices)  Please fax once only – if checking, please call  All referrals triaged by Hepatologist for medical urgency  Booked on medical urgency basis only  Appointment letters are faxed back to your office Patient Information – Print Clearly or affix label Last, Gender M Apt City Non-English – Language Spoken: First F DOB: DD MM YYYY Address Prov Postal Code H: C: Health Card # ( or IFH or UHIP) VC PROV Referring Physician PRINT CLEARLY Signature *** OHIP Provider # *** OR STAMP HERE: Suite # : Address: City Prov PH: Postal Code FX: **Required** E MR r e f e r r a l s a r e a c c e p t a b l e i f A L L i n f o r m a t i o n i s c o m p l e t e & R E Q U I R E D t e s t s a t t a c h e d ( n o t p e n d i n g ) Family Doctor – if different than referring - PRINT CLEARLY Patient: Pg 2 For UHN only –  all tests in EPR ** ENSURE ALL LISTED TESTS ARE ATTACHED (NOT pending) ** For ALL patients (even previous) except as noted MUST be recent (< 6 MONTHS) REASON FOR REFERRAL (or QUESTION to be answered): Hep B HBV Pre-Chemo (**if HBV sAg+) SEND: HBV DNA(PHL report), CBC, creatinine, ALT, AST, ALP, bilirubin, INR, albumin, HBsAg, anti-HBs, HBeAg, anti-HBe, abdominal ultrasound *If applicable: Treatment records with dates & viral loads Hep C (**if HCV Ab+) SEND: HCV PCR & Genotype (PHL report) (NOT req. for previous pts) CBC, creatinine, ALT, AST, ALP, bilirubin, INR, albumin, abdominal ultrasound Treatment Naïve or *If applicable: Treatment records with dates & viral loads Elevated LFT’s, Autoimmune/PBC/PSC, NAFL/NASH SEND: ALL patients (even previous): CBC, creatinine, ALT, AST, ALP, bilirubin, INR, albumin, HBsAg, anti-HBs, HBeAg, anti-HBe, abdominal ultrasound NEW patients (PLUS): HBsAg, anti-HBc & anti-HCV, HBeAg, anit-HBe, iron saturation, & ferritin, quantitative Immunoglobulins, ANA, AMA & SMA, ceruloplasmin, Liver biopsy report (if done) 2nd Opinion OR: All Other Conditions – please indicate reason/details  Patient is pregnant Due Date: (**important for Hep B patients) Additional Clinical Information: (please add additional pages and reports if required) E MR r e f e r r a l s a r e a c c e p t a b l e i f A L L i n f o r m a t i o n i s c o m p l e t e & R E Q U I R E D t e s t s a t t a c h e d ( n o t p e n d i n g )