Liver Clinic Referral Form - University Health Network

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EMR referrals are acceptable if ALL information is complete & REQUIRED tests attached (not pending) CLINICIANS No Preference – 1 st Available ** Hepatologists Dr. Morven Cunningham Dr. Jordan Feld Dr. Aliya Gulamhusein Dr. Gideon Hirschfield Dr. Harry Janssen Dr. Keyur Patel Dr. Hemant Shah Dr. David K. Wong Clinical Associates Dr. Navjot Deol Dr. Joshua Juan Nurse Practitioners Elizabeth Lee, NP Colina Yim, NP We share referral triaging and will, as appropriate, assign staff based on availability or patient’s medical requirements. PATIENT INFORMATION University Health Network Toronto General Hospital 200 Elizabeth St - 13N Norman Urquhart Bldg. Toronto, ON M5G 2C4 www.torontoliver.ca PHONE: 416-340-4868 option 1 FAX: 416 340 4280 Clinic Notes are available on ConnectingOntario - - - WE ARE A LIVER MEDICINE FOCUSED PROGRAMME - - - Please do not refer undifferentiated liver masses in the absence of underlying liver disease Hep B & C referrals: please ensure HBV DNA and HCV PCR are available at time to triage ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Provide info where applicable - Our Hepatologists will ultimately triage based on established guidelines Other referral information: ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________ URGENT Acute icteric/severe hepatitis Decompensated cirrhosis Suspected malignant PRIMARY liver mass HBV for immediate pre-chemo prophylaxis Last, First Gender M F DOB: DD MM YYYY Apt Address City Prov. Postal Code H: C: __________________________________ _______ _______ Health Card # (or IFH or UHIP) VC PROV (IFH or UHIP: send certificate with referral) COMPLETE FORM with LABS & REPORTS AND FAX TO 416-340-4280 ER GP GIM GI/HEP Other: _______________ Referring STAFF Clinicians (not residents/fellows) PRINT CLEARLY ______________________________________________________ Lic.# or CPSO/CNO# ____________ OHIP Provider# ____________ Ref Phone # ________________________________ Ref Fax # ________________________________ SEMI–URGENT New cirrhosis Hep B with elevated liver enzymes > 2 ULN Elevated liver enzymes > 5 ULN 2 nd opinion referrals from community GI NON–URGENT NAFLD/abnormal LFTs Hemangioma/FNH Stable Hep C Stable Hep B/normal liver enzymes Polycystic liver disease Referral from Oncology/Haematology Primary diagnosis __________________ Proposed chemotherapy regimen (if applicable) ________________________ Chemo start date ___________________ List Medication: ___________________________________________________ REASON FOR REFERRAL Alcohol Autoimmune Focal Liver Lesion NAFLD/NASH Viral Hepatitis B Viral Hepatitis C Other: _________________________________ Patient Pregnant Delivery Date: ___________ OTN eConsult also available via otnhub.ca - Group: Toronto UHN Hepatology (Liver) Consult Group

Transcript of Liver Clinic Referral Form - University Health Network

Page 1: Liver Clinic Referral Form - University Health Network

EMR referra ls are acceptable i f ALL in format ion is comple te & REQUIRED tests at tached (not pending)

CLINICIANS No Preference – 1st Available **

Hepatologists Dr. Morven Cunningham Dr. Jordan Feld Dr. Aliya Gulamhusein Dr. Gideon Hirschfield

Dr. Harry Janssen Dr. Keyur Patel Dr. Hemant Shah Dr. David K. Wong

Clinical Associates Dr. Navjot Deol Dr. Joshua Juan

Nurse Practitioners Elizabeth Lee, NP Colina Yim, NP We share referral triaging and will, as appropriate, assign staff based on availability or patient’s medical requirements.

PATIENT INFORMATION

University Health Network Toronto General Hospital 200 Elizabeth St - 13N Norman Urquhart Bldg. Toronto, ON M5G 2C4 www.torontoliver.ca PHONE: 416-340-4868 option 1 FAX: 416 340 4280 Clinic Notes are available on ConnectingOntario

- - - WE ARE A LIVER MEDICINE FOCUSED PROGRAMME - - -Please do not refer undifferentiated liver masses in the absence of underlying liver disease Hep B & C referrals: please ensure HBV DNA and HCV PCR are available at time to triage

----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Provide info where applicable - Our Hepatologists will ultimately triage based on established guidelines

Other referral information: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

URGENT Acute icteric/severe hepatitis

Decompensated cirrhosis

Suspected malignant PRIMARY liver mass

HBV for immediate pre-chemo prophylaxis

Last, First

Gender M F DOB: DD MM YYYY

Apt Address

City Prov. Postal Code

H: C:

__________________________________ _______ _______ Health Card # (or IFH or UHIP) VC PROV (IFH or UHIP: send certificate with referral)

COMPLETE FORM with LABS & REPORTS AND FAX TO 416-340-4280

ER GP

GIM GI/HEP

Other: _______________

Referring STAFF Clinicians (not residents/fellows) PRINT CLEARLY

______________________________________________________

Lic.# or CPSO/CNO# ____________ OHIP Provider# ____________

Ref Phone #

________________________________

Ref Fax #

________________________________

SEMI–URGENT New cirrhosis

Hep B with elevated liver enzymes > 2 ULN

Elevated liver enzymes > 5 ULN

2nd opinion referrals from community GI

NON–URGENT NAFLD/abnormal LFTs

Hemangioma/FNH

Stable Hep C

Stable Hep B/normal liver enzymes

Polycystic liver disease

Referral from Oncology/Haematology

Primary diagnosis __________________ Proposed chemotherapy regimen (if applicable) ________________________

Chemo start date ___________________ List Medication: ___________________________________________________

REASON FOR REFERRAL

Alcohol Autoimmune Focal Liver Lesion NAFLD/NASH

Viral Hepatitis B Viral Hepatitis C Other: _________________________________

Patient Pregnant

Delivery Date: ___________

OTN eConsult also available via otnhub.ca - Group: Toronto UHN Hepatology (Liver) Consult Group

http://www.torontoliver.ca/

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