Document 6524396

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 )