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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. Symons Vall Vall Symons Stoney Trail NW ey Booking An Appointment Ph CGY:Ha 403.212.5855, Ph EDM: 780.341.6000 PLEASE BRING THIS REQUISITION FORM AND Road NW rv Appointments may be booked Toll-Free est Ph: 1.877.420.4CDC (4232) HEALTHCARE CARD TO YOUR EXAM Hills by either the practitioner or Fax CGY:Blvd 403.253.4669 • Arrive 15 minutes prior to your exam unless notified otherwise Country Hills Blvd NW N the patient, please haveSh Toll-Free Fax: 1.877.919.3291 • Our clinics are scent free - Please refrain from the wearing of ag an ap y BeddingtonEmail: [email protected] scented products healthcare card and pi lley Tr ymonsail Va St. Albert requisition form available.S Online Requests: CanadaDiagnostics.ca • Please bring an adult to supervise children underN.W. the age of 12 Trail NW Rd. Calgary Drive l International l Hebert Rd. e b CALGARYS Nose Hill Airport EDMONTONp ym a m C St. Albert Manning ons Va St. 97 Crowchild John Laurie Symons Valley Pkwy 137 Ave 3 V i Trail c 2 Street t Symons Valley Boulevard N.E. o r North St. 66 i a Deerfoot 12 St. N.E. Trail Blvd. McKnight 52 Street N.E. 68 Street N.E. 9 St. 82 Rd. T 127 St. 127 mount Drive 36 Street N.E. Fort r a S Trail Barlow Trail i l Road NW h a l Groat g ley 16 a 1 Centre n on 32 Ave. N.E. 120 Ave a Trail St. 50 Yellowhead Tr. p Trans - 4 Street N.W. Yellowhead 118 Ave 118 Ave Hwy.16 Shag 32 Ave. Trail 1 pi 16 Road Bowness Kingsway CanadaBeddington R 8 St. Ave anappi Edmont T Trail NW 97 112 r St. 142 a Hwy. o 111 Ave 2 Drive i l N.W. Trans - Canada Hwy. 97 ad 1 St. Stoney Trail NW 107 Ave Trail Road 106 Ave 109 St. 109 170 2 7 St. Blvd. N Stony Plain Rd. Hwy.16A Sherwood Stoney Trail Stoney SHERWOOD PARK Drive St. 84 morial Dr.5 68 St. Baseline Road BaselineBaselineRoad Road Bow Me W ial 16A r 100 Ave Dr. 14 St. o 98 Ave Sherwood St. Connors Trail m 6 Ave. e ParkDr 9 Ave. M ewa Rd ewa 5 50 St. 9 Ave. 149 Rd. Sha Trail 17 Avenue S.E. 82 Ave. Whyte Dr 17 Ave. S.W. 17 Ave. S.W. Ave 4 Chipp 1A Dr. Henday Sioux Broadmoor Wye Sherwood 36 Street S.E. Road WhitemudDr. 75 St. Wye Road Rd Blvd 4 St. S.W. Anthony Henday Anthony 114 St. 114 6 99 St. 99 109 St. 109 104 St. 104 Trail Trail 69 St. S.W. St. 69 g 26 Street S.E. 63 Ave Anthony Sarcee 61 Ave Beddington St. 113 Richmond Road S.W. St. 14 an Broadmoor Anthony Henday Anthony 42 Ave. S.E. 122 St. Blackfoot 51 Ave Wye Road 10 ridge 8 TraiOKOTOKS Whitemud Crowchild Glenmore Crowchild 50 Avenue S.E. 3 W Trail Drive North North app t N. Railway 52 Street S.E. N o Ring o Drive Dr. 58 Ave. f Freeway East l r Trail e 2A l ai e St Road 2 119 St. D r Southridge N 34 Ave. illegar 8 50 St. Macleod Glenmore W 2 Trail Woodha Terw Barlow Trail S.E. ven Dr St. 111 i Elbow 2 23 Ave. S.W. Stoney T Fairmont Trail Glenmore Trail 91 St. Heritage Dr. Dr T Trail 6 4 Dr ra 90 Ave. Cimarron Anthony Henday Drive 1 Ellerslie Road SW 14 St. Drive Queen Elizabeth Hwy Elizabeth Queen il Southland Drive S.E. 24 St. S.W. St. 24 Anderson Road Locations Blvd. Locations 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.
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