28 - Other

Relevant co-morbidity

  • History of stroke
  • Cardiovascular disease (e.g. Prior MI)
  • Respiratory disease
  • Peripheral Vascular Disease
  • GI Disease (e.g. Crohns)
  • Renal disease
  • Liver disease (e.g. Hepatitis B or C)
  • Diabetes
  • Rheumatologic disease (e.g. SLE, Scleroderma etc) 
  • Active infections (e.g. MRSA, Shingles, TB, VRE)
  • HIV
  • Cognitive Issues
  • Any other concurrent medical problem
  • Sleep Apnea with CPAP

  • Medication history Including Antithrombotics (type and reason) and Insulin / Oral hypoglycemic agent

  • Copy of any relevant diagnostic imaging - copy of image and the report

Luminal Referral Form 

Liver Referral Form

Fax completed referral package to


Any concerns or questions please call

Central Referrals: 780-248-1935 ​