ECCQ Fibroscan® Referral (for Migrants and Refugees only)



Referring Doctor Details:Dr Name:Practice Name:Practice Address:Phone number:Fax:Email: Is your practice able to provide a room for FibroScan? to be performed in-house? 8953507222932258073158Yes: No: Doctor Signature:Date of Referral: / / Patient Details:Family Name:Given Name:Date of Birth: / / 121793024130Sex: Male: 121856515240 Female: 12204705715 Non-binaryPost Code: Phone:Aetiology of Liver Disease:77724029684Hepatitis B: 77724024604Hepatitis C: Language Spoken at Home:Interpreter Required:8089902159029527521116Yes: No: Country of Birth:FibroScan cannot be performed if your patient has ascites or is under 18 years of age. Reason for Referral: Baseline assessment of fibrosis: 3718560187325 Re-Assess level of fibrosis (2-3 yearly) Pre-Treatment Assessment: Other (please specify):Recent Blood test results <1 month if availableALT: U/L (<200 U/L. FibroScan? contra-indicated if > 200) Please email this completed form to: referrals@.au Or fax to: (07) 3844 3122Office Use only.Date Referral received:208327419050155156119998Appropriate referral: Yes: No: Appointment date: Location FibroScan? to be performed at: Name of BCHW to attend: or Interpreter Booked: Name: Time: ................
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