FIBROSCAN REQUEST FORM

Date  <TodaysDate>

Re: Patient Label 
                     <PtFullName>
Address       <PtAddress>
Sex              <PtSex>
Telephone (H)  <PtPhoneH>		(Mobile)  <PtPhoneMob>		(Work)  <PtPhoneWk>

1.	Indication For Assessment:

Note: FibroScan use is validated in patients with hepatitis B/C, alcoholic liver disease, chronic cholestatic diseases & HCV/HIV co-infection.
2.	Physical Examination: Stigmata of Chronic Liver Disease?	YES / NO
		If yes please specify:

3.	Previous Liver Biopsy: Date_________ Fibrosis score__________________
4.	
Date		
ALT		
AST		
Platelets		

Note: Elevated Liver Function Tests can interfere with FibroScan results
We request that all patients FAST for 2 HOURS prior to FibroScan

Referring Doctor:   <DrName>
Provider Number:  <DrProviderNo>
Address:                  <DrAddress>
Fax No:                    <DrFax>