Ph CGY: 403.212.5855, Ph EDM: 780.341.6000 Toll-Free Ph: 1.877.420.4CDC (4232) Liver; Special Studies Fax CGY: 403.253.4669 Toll-Free Fax: 1.877.919.3291 SUBMIT BY EMAIL HERE Email: [email protected] Online Requests: CanadaDiagnostics.ca

Patient & Appointment Information Date of Requisition: DD/MM/YY Physician Name Referring Physician

Address Clinic

City Province Postal Code Phone

Home Phone Other Phone Fax DOB DD/MM/YY Male Female Weight [lbs / kg] Copy to Dr. AHC# Fax Copy to Dr.

PRAC ID Appt. Date Time CDC Site Signature Clinical History

N. A. F. L. D (Non-Alcoholic Fatty Liver Disease) H. C. C. Screening (Hepatocellular Carcinoma)

Risk factor for NAFLD present: Book patient for serial follow up exam Obesity, hyperlipidemia, metabolic syndrome and/or type 2 diabetes Ethnicity: Asian Caucasian African descent Other

Ultrasound has confirmed fatty liver (steatosis) Eligible Patients:

Medication and lifestyle factors that may be the cause or contribute to Hepatitis B carriers (HBsAg +) who are: fatty liver and/or abnormal liver tests: Asian males > 40 years old Alcohol consumption Asian females > 50 years old 2+ drinks per day for males African > 20 years old 1+ drink per day for females Patients with a family history of HCC Medications HIV co-infected Corticosteroids Tamoxifen Methotrexate Amiodarone OR

Cirrhosis Abnormal Liver Test Elevated ALT and/or AST (for > 6 months) Fibroscan Score Biopsy Diagnosis Clinical Diagnosis Other Virology Performed Cause of Cirrhosis: (Check all that apply) Hep B (+) (-) Hep B Hep C ETCH PBC PSC NAFLD Hep C (+) (-) Alpha 1 anti-trypsin deficiency Hemachromatosis

Wilson’s Disease AIH (auto immune) Other Required Information Height (cm) Weight (kg) BMI Prior Imaging Known Benign Liver Lesion: Yes No Known Malignant Liver Lesion: Yes No

CanadaDiagnostics.ca Procedure availability & hours of operation vary by CDC location.

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1 Brentwood 6 Okotoks 1 Ellerslie 4 Sherwood Park (H.C.C. Only) 830-3630 Brentwood Rd NW, T2L 1K8 141-31 Southridge Dr, T1S 2N3 632 91 St SW, T6X 0E4 114-80 Chippewa Rd, T8A 4W6 Ph: 403.338.4000 Ph: 403.995.2727 Ph: 780.341.6020 Ph: 780.467.2773 Fax: 403.210.0075 Fax: 403.995.2737 Fax: 587.458.5581 Fax: 780.467.2982 2 Chinook 7 Pacific Place 1-6020 1A St SW, T2H 0G3 959-999 36 St NE, T2A 7X6 Ph: 403.253.4666 Ph: 403.215.2900 Fax: 403.301.2073 Fax: 403.215.2920 2 Mira 5 Westgate 8 Sunridge 103-11910 111 Ave NW, T5G 0E5 172-17010 90 Ave NW, T5T 1L6 Ph: 780.452.9711 Ph: 780.484.1672 3 Calgary Women’s Imaging Centre* 3-2675 36 Street NE, T1Y 6H6 20 Richard Way SW, T3E 7M9 Ph: 403.291.3315 Fax: 780.452.3451 Fax: 780.484.2982 Ph: 403.685.3123 Fax: 403.291.9308 Fax: 403.685.3235 9 Symons Valley 4 Glenmore Landing (H.C.C. Only) 32-12192 Symons Valley Rd NW, 3 North Town 6 109 Street* D270-1600 90 Ave SW, T2V 5A8 T3P 0A3 134-9450 137 Ave NW, T5E 6C2 7121 109 St NW, T6G 1B9 Ph: 403.252.5882 (Creekside Shopping Centre) Ph: 780.478.7221 Ph: 780.434.9147 Ph: 403.212.5640 Fax: 403.640.2948 Fax: 780.475.1860 Fax: 780.436.7650 Fax: 403.212.5642 5 Marlborough 10 Westhills 411 Marlborough Way NE, T2A 7E7 200A Stewart Green SW, T3H 3C8 *Walk-in X-ray not available at these locations Ph: 403.273.9002 Ph: 403.685.6175 Fax: 403.569.8097 Fax: 403.685.6199

Exam Preparation You may also visit prepare.CanadaDiagnostics.ca

GENERAL NAFLD ENHANCED PRIMARY CARE PATHWAY • Please arrive 15 minutes in advance of your appointment time. For more information the clinical care of these patients, • Confirming your identification is essential to ensure accurate please see: medical records and for your protection and security. https://www.specialistlink.ca/files/Enhanced_Primary_Care_Pathway_NAFLD • You will be asked at EACH VISIT to provide a VALID HEALTH CARE CARD _10January2018.pdf and PICTURE ID. • If you do not have your card you may be asked to return for HCC SCREENING your examination. The HCCRADS read as follows: • Please bring your requisition with you. 0 - Exam limited or non-diagnostic • Phone to cancel if unable to keep booked appointment. Liver evaluation or follow up with alternate modality recommended. • Please notify reception if you are diabetic. 1 - No mass or suspicious findings. • Patients suspecting pregnancy should consult their physician No sonographic evidence or worrisome mass or nodule. Patient rebooked for before exam date. surveillance scan in 6 months time. 2 - Lesion is 10 mm or less in size. This finding warrants close follow up and this LIVER ULTRASOUND PATIENT PREPARATION patient will have this examination repeated in 3 months time. • Do not eat for 6 hours prior to exam. • Clear fluids allowed. No milk or cream. 3 - Hepatic nodule greater than 10 mm in size detected. This finding warrants diagnostic testing to assess for features of HCC. Referral to hepatologist for

CanadaDiagnostics.ca definitive work-up suggested. 2109.02.20 CanadaDiagnostics.ca