Referral Form

Self or provider referrals

accepted

General Information

Name: Cezonia Doxtator

Birthdate (DD/MM/YYYY): 05/09/1985
Health Card Number: 3778175178TX
Address: 1416 Ernest Ave #205
Phone Number: 226-385-7964
Source of Income: Ontario works Drug Plan:
Family Physician:
Phone: Fax:

Reason for Referral:

- Screening (HCV Antibody - Outreach and Peer Support/Community
Testing) HCV-PCR Supports
(Genotype and Viral - Assistance with connection to
Load/Chronic Hep C) community services
- Supportive Counselling and - Treatment
System Navigation

Hepatitis C History:
Known Hepatitis C risk factors or source of transmission (Blood transfusion, injection drug use, sharing
personal hygiene items, jail, etc) AND if they have been treated previously (where, what medication,
ordering provider):
Drug use, positive for anti body thru
hepcure”

Please attach the following laboratory investigations if they have been done:
- HCV antibody, Viral Load and Genotype - CBC
- HbA1C - Hep A and B immune status + Hep B sAg and cAb
- HIV - Fibroscan
- Creatinine, Liver Enzymes and Liver function test - Abdominal ultrasound

Referring Agency/Provider
Date:
February 7/23
Signature: Cezonia Doxtator Relationship to Client: Self referral
Phone: Fax:
Please fax completed form to the Hepatitis C Care Team at 519-642-1532
Updated September 2020