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{"name": "labs-58b652e4-ed4b-42f1-a594 {"name": "labs-58b652e4-ed4b-42f1-a594-1e2c961e8006.pdf", "content_type": "application/octet-stream", "size": 421092, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-d2e097e4-edab-4b1c-8f81-f2f31baa99a1"}...
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{"status": "completed", "conte {"status": "completed", "content": "22071(2023-07)\n18637 (2021-10)\nScanning Label or Accession # (lab only)\nProvider(s)\n Patient\nCollection\nPHN\nExpiry: ________\nDate of Birth (dd-Mon-yyyy)\nLegal Last Name Legal First Name Middle Name\nAlternate Identifier Preferred Name o Male o Female\no Non-binary o Prefer not to disclose\nPhone\nAddress City/Town Prov Postal Code\nAuthorizing Provider Name (last, first, middle) Copy to Name (last, first, middle) Copy to Name (last, first, middle)\nAddress Phone Address Address\nCC Provider ID CC Submitter ID Legacy ID Phone Phone\nClinic Name Clinic Name Clinic Name\nDate (dd-Mon-yyyy) Time (24 hr) Location Collector ID\nFor detailed testing information, refer to \nAPL Test Directory (http://ahsweb.ca/lab/apl-td-lab-test-directory)\nAntiphospholipid Syndrome Investigation\nRequisition\nTest(s) \nRequested\nPlease use this requisition only for Lupus anticoagulant / Antiphospholipid Syndrome Investigation. If other\nspecial coagulation testing is required please use the appropriate Hemostasis or Thrombosis Investigations\nrequisition.\nIs the patient currently on any anticoagulants?\n (Select all that apply)\n\uf06f None \uf06f Heparin (unfractionated or low-molecular) \uf06f Vitamin K Antagonist (eg. warfarin)\n\uf06f Other (eg. apixaban, rivaroxaban, fondaparinux, dabigatran, etc) ____________________________________________________\nReason for testing: (select all that apply)\n\uf06f Thromboembolism\n\uf06f Autoimmune Disorder\n\uf06f Fertility Investigation\n\uf06f Pregnancy Loss\n\uf06f Prolonged PTT\n\uf06f Other ________________________________________________________________________________\n\uf06f Lupus Anticoagulant\n\uf06fAnti-cardiolipin Antibody\n\uf06fAnti-beta-2-glycoprotein Antibody\nAnswer all questions\n578788878\n1998-12-11\nKash\nDiv\n52 Castlefall Way NE\nCaglary\nChoose Province\nT3J1M7\nMequanent\nTed\n1"}...
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{"name": "labs-56c78c4b-0e5e-445f-9cb3 {"name": "labs-56c78c4b-0e5e-445f-9cb3-442b3ef0ddbc.pdf", "content_type": "application/octet-stream", "size": 9, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}}...
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{"name": "labs-54387967-4ff6-4f6a-8fc9 {"name": "labs-54387967-4ff6-4f6a-8fc9-fc22a230e723.pdf", "content_type": "application/octet-stream", "size": 640799, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-1397a3c4-2191-490b-b267-f2154eed2c27"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash testing\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"name": "labs-51f0d871-77cd-4edc-954b {"name": "labs-51f0d871-77cd-4edc-954b-f6e8c7a52d64.pdf", "content_type": "application/octet-stream", "size": 314633, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-47a99f56-2031-421e-9296-8535d94d89a1"}...
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{"status": "completed", "conte {"status": "completed", "content": "For more information visit www.myhealth.alberta.ca\nWho can I call with questions?\nHealth Link Alberta 1.866.408.5465 These recommendations are aligned with Choosing Wisely Canada.\nWho needs \nvitamin D testing?\n\u2022\t While\tthere\tis\tgood\tscientific\t\nevidence that all Albertans need \nmore vitamin D through foods and \nsupplements, there is no good \nevidence to support regular blood \ntesting to determine vitamin D \nlevels for most of us, except in \nmedically necessary cases.\n\u2022\t Medically\tnecessary\tcases\t\ninclude: those with osteoporosis \nor other bone-thinning diseases, \nmalabsorption syndromes, \nrenal disease, rickets, or patients \ntaking drugs that affect vitamin D \nabsorption.\nWhy do you \nneed vitamin D?\n\u2022\t Vitamin\tD\thelps\tour\tbodies\tbuild\t\nstrong, healthy bones and teeth. It \nmay also lower your risk for heart \ndisease, cancer, diabetes, high \nblood pressure and other diseases.\n\u2022\t Your\tbody\tneeds\tVitamin\tD\tto\t\nabsorb calcium, and without \nenough calcium, your muscles \ncan cramp, hurt, or feel weak. \nYou\tmay\thave\tlong-term\tmuscle\t\naches and pains. If you don't get \nenough vitamin D throughout your \nlife, you are more likely to have \nthin and brittle bones (known as \nosteoporosis) in your later years.\nHow do you get \nenough vitamin D?\n\u2022\t Our\tskin\tmakes\tsome\tVitamin\tD\t\nfrom sunlight; but because of our \nlong winters, most Canadians \nmake little or no vitamin D \nbetween\tOctober\tand\tMarch\tand\t\nneed to get it from other sources. \n\u2022\t As\ta\tresult,\ta\tvery\timportant\tway\t\nof getting enough vitamin D is \nthrough the food we eat. This \nincludes foods like egg yolks, liver, \nand\tfish\tsuch\tas\tchar,\therring,\t\nmackerel, salmon, sardine and \ntrout.\tEating\tfish\ttwice\ta\tweek\t\nthrough healthier cooking methods \nsuch as poaching, baking, or \nbarbequing is a great way to \nsupplement your vitamin D intake. \nvitamin D can also be found in 2-3 \nservings\tof\tmilk\tand/or\tfortified\tsoy\t\nor rice beverage each day. \n\u2022\t In\taddition\tto\tVitamin\tD\tfrom\t\nfoods, at minimum most children \nand adults require a 400 IU \nsupplement daily, but no more \nthan 1,000 IU. Adults over the age \nof 70 require at minimum an 800 \nIU supplement daily, but no more \nthan 2,000 IU. For most people, \nthe best supplement is vitamin D3. \nVitamin D \nand your \nhealth"}...
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{"name": "labs-44b7a0cf-72c9-4639-a00f {"name": "labs-44b7a0cf-72c9-4639-a00f-1e8f2bbbae75.pdf", "content_type": "application/octet-stream", "size": 641036, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-d2130eb1-b70f-41fb-90c5-c58f97da0f2a"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash abcd\nDiv ctg\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"name": "labs-3f45ad90-c5c6-4c27-880e {"name": "labs-3f45ad90-c5c6-4c27-880e-5d6bcb2dce56.pdf", "content_type": "application/octet-stream", "size": 640549, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-4216a88e-73ea-4e7f-8727-0299f18344da"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"name": "labs-395046e6-65c6-42e0-b3b6 {"name": "labs-395046e6-65c6-42e0-b3b6-3f025b2469f8.pdf", "content_type": "application/octet-stream", "size": 640962, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-a9ada0da-11ad-410d-8198-19a31632c6a8"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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labs-383536f7-5f0a-4ac2-8353-70d9b6e66d5f.pdf
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{"name": "labs-383536f7-5f0a-4ac2-8353 {"name": "labs-383536f7-5f0a-4ac2-8353-70d9b6e66d5f.pdf", "content_type": "application/octet-stream", "size": 640549, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-3121beae-9e1f-48ce-9488-8ef0f5d8ddb3"}...
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374bfccd1eb4a0c7d40839532ae6c712cbe3674b92845fcf38 374bfccd1eb4a0c7d40839532ae6c712cbe3674b92845fcf38976ea3f8450d0e...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"name": "labs-33c238b6-c04b-4e78-8652 {"name": "labs-33c238b6-c04b-4e78-8652-cbb09d8b6379.pdf", "content_type": "application/octet-stream", "size": 9, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}}...
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{"status": "failed", "error {"status": "failed", "error": "Stream has ended unexpectedly"}...
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labs-31d96f29-bb34-4efe-8391-6f2a16cede85.pdf
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{"name": "labs-31d96f29-bb34-4efe-8391 {"name": "labs-31d96f29-bb34-4efe-8391-6f2a16cede85.pdf", "content_type": "application/octet-stream", "size": 640563, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-154c1ccd-1441-43b2-8aa9-277a60fd2c67"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"name": "labs-2f83ce40-6dea-4829-836c {"name": "labs-2f83ce40-6dea-4829-836c-54d23b3cd826.pdf", "content_type": "application/octet-stream", "size": 640563, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-08bf338f-2a95-48ff-8f52-12fc4f77e1be"}...
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374bfccd1eb4a0c7d40839532ae6c712cbe3674b92845fcf38 374bfccd1eb4a0c7d40839532ae6c712cbe3674b92845fcf38976ea3f8450d0e...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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labs-2a4c4482-144b-4b6e-94e9-c73a715b7d7b.pdf
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{"name": "labs-2a4c4482-144b-4b6e-94e9 {"name": "labs-2a4c4482-144b-4b6e-94e9-c73a715b7d7b.pdf", "content_type": "application/octet-stream", "size": 640800, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-12275b51-4375-41df-afe0-d1eaa65daa6c"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash abcd ed\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"name": "labs-2872986e-6042-4c34-8299 {"name": "labs-2872986e-6042-4c34-8299-235fb0f884d8.pdf", "content_type": "application/octet-stream", "size": 640549, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-0331aefe-f5b3-41cb-80ca-7f637f18d5d6"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"status": "completed", "conte {"status": "completed", "content": "22071(2023-07)\n18637 (2021-10)\nScanning Label or Accession # (lab only)\nProvider(s)\n Patient\nCollection\nPHN\nExpiry: ________\nDate of Birth (dd-Mon-yyyy)\nLegal Last Name Legal First Name Middle Name\nAlternate Identifier Preferred Name o Male o Female\no Non-binary o Prefer not to disclose\nPhone\nAddress City/Town Prov Postal Code\nAuthorizing Provider Name (last, first, middle) Copy to Name (last, first, middle) Copy to Name (last, first, middle)\nAddress Phone Address Address\nCC Provider ID CC Submitter ID Legacy ID Phone Phone\nClinic Name Clinic Name Clinic Name\nDate (dd-Mon-yyyy) Time (24 hr) Location Collector ID\nFor detailed testing information, refer to \nAPL Test Directory (http://ahsweb.ca/lab/apl-td-lab-test-directory)\nAntiphospholipid Syndrome Investigation\nRequisition\nTest(s) \nRequested\nPlease use this requisition only for Lupus anticoagulant / Antiphospholipid Syndrome Investigation. If other\nspecial coagulation testing is required please use the appropriate Hemostasis or Thrombosis Investigations\nrequisition.\nIs the patient currently on any anticoagulants?\n (Select all that apply)\n\uf06f None \uf06f Heparin (unfractionated or low-molecular) \uf06f Vitamin K Antagonist (eg. warfarin)\n\uf06f Other (eg. apixaban, rivaroxaban, fondaparinux, dabigatran, etc) ____________________________________________________\nReason for testing: (select all that apply)\n\uf06f Thromboembolism\n\uf06f Autoimmune Disorder\n\uf06f Fertility Investigation\n\uf06f Pregnancy Loss\n\uf06f Prolonged PTT\n\uf06f Other ________________________________________________________________________________\n\uf06f Lupus Anticoagulant\n\uf06fAnti-cardiolipin Antibody\n\uf06fAnti-beta-2-glycoprotein Antibody\nAnswer all questions\n578788878\n1998-12-11\nKash\nDiv\n52 Castlefall Way NE\nCaglary\nChoose Province\nT3J1M7\nMequanent\nTed\n1"}...
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{"name": "labs-1ba6ff84-c1ba-43f4-a669 {"name": "labs-1ba6ff84-c1ba-43f4-a669-77b907d19f4d.pdf", "content_type": "application/octet-stream", "size": 647628, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-48ce31bd-919e-4259-a8f8-02ffba083d64"}...
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{"status": "completed", "conte {"status": "completed", "content": "Chemistry Specialty Requisition\nCH-0311(Rev2023-04)\nLaboratory Medicine and Pathology\nEdmonton Zone Laboratory Services\nClient Response Centre 780-407-7484\nFasting\n# of hrs\nSpecimen Type\nBlood \u00a3 Serum \u00a3 Plasma\n\u00a3 Whole blood\n\u00a3 m\\Microcollection\nUrine / Feces \u00a3 Random \u00a3 24 hr \n\u00a3 Timed, other ________________\nTotal volume __________________\nStart time/date ________________\nStop time/date ________________\nOther ________________________\nBill Type\n CPL \u00a3 Alberta Health Care OT \u00a3 Out of Prov\nCCO \u00a3 Alberta Health Care Third Party XX \u00a3 Pre-paid\nCO \u00a3 DynaLIFEDX PB \u00a3 Patient Bill\nCo. name ________________________________________________\nAddress _________________________________________________\nClient # __________________________________________________\nSpecimen Event Type\nIA \u00a3 AUXILIARY HC \u00a3 HMCARE\nIP \u00a3 IN PT ST \u00a3 STAFF\nOP \u00a3 OUT PT EN \u00a3 ENVIRON\nAP \u00a3 AMBUL WCB \u00a3 WORKER'S \n COMP\nVITAMIN D\n25VD o 25-Hydroxy Vitamin D\nTesting that does not meet the criteria \nlisted below will NOT be preformed:\n(Check all that are appropriate for your \npatient)\no\nMetabolic bone diseases\no Abnormal blood calcium\no Malabsorption syndromes\n(celiac disease, small intestine surgery,\nanticonvulsant agents)\no Chronic renal disease\no Chronic liver disease\nANTI-NUCLEAR ANTIBODY SCREEN\nANA o Anti-Nuclear Antibody Screen\nANA lacks specificity (high false positive \nrate) as a diagnostic test in the absence \nof relevant clinical symptoms. \nAt least two of the criteria listed below \nshould be identified. \no\nPhotosensitive (\"lupus\") rash\no Arthritis\no Myositis\no Oral ulcers\no Pleurisy or pericarditis\no Glomerulonephritis\no Hemolytic anemia, thrombocytopenia,\nneutropenia or lymphopenia\no Seizures or psychosis\no Raynaud's phenomenon\no Scleroderma skin changes\no Alopecia Areata\no Sicca (dry mouth/dry eyes)\no Suspected Juvenile Arthritis\nBIOCHEMICAL GENETICS\nStrict attention to recommended specimen \ncollection procedures is required. Information \ncan be obtained from \"Guide to Lab Services\" \nor by calling Client Response Centre.\nTPN (last 72 h) o Yes o No\nTransfusion (last 90 days) o Yes o No \nPlasma\nAAQ o Amino Acid Quantitation\nBTDQ o Biotinidase\nBlood\nACBS o Acylcarnitine, Blood Spot\nLCARA o Arylsulfatase A\nLCARB o Arylsulfatase B\nFABRY o Fabry\nGALSC o Galactosemia Screen\nGAUCH o Gaucher\nBGALA o GM1 Gangliosidosis\nPOMPE o Pompe\nKRABBE o Krabbe\nUrine\nUAAQ o Amino Acid Quantitation\nUCYST o Cystinuria Screen\nMPSCS o Mucopolysaccharide Screen\nOLIGO o Oligosaccharide Screen\nORGLC o Organic Acids\nSUGID o Sugar Screen\nUSULF o\tSulfite\tScreen\nStool\nFRED o Reducing Substances\nCSF\nSFAAQ o Amino Acid Quantitation\nTRACE ELEMENTS\nStrict attention to recommended specimen collection procedures \nis required. Information can be obtained from \"Guide to Lab \nServices\" or by calling Client Response Centre.\nPlease complete the following\nEnvironmental exposure to certain trace elements either \noccupationally or in food / medications can cause elevated \ntrace element concentrations. Previous administration \nof GADOLINIUM- or BARIUM-CONTAINING CONTRAST \nMEDIA is known to cause interference with trace elements \ndeterminations.\nOccupational exposure o Yes o No\nDate of exposure ______________ Time of exposure ________\nTrace elements suspected _______________________________\nSerum Whole Blood Urine\nAluminium o ALU o UAL\nAntimony o WBSB o USB\nArsenic o WBAS o UAS\nBarium o SBA o UBA\nBeryllium o SBE o UBER\nBismuth o UBI\nCadmium o BCDM o UCD\nChromium o SCRM o UCRM\nCobalt o WBCO o UCOB\nCopper o SCU o UCU\nLead o WBPB o UPB\nManganese o BMN o UMN\nMercury o WBHG o UHG\nMolybdenum o WBMO\nNickel o NIK o UNIK\nSelenium o SSE o USEL\nThallium o WBTL o UTHAL\nZinc o SZN o UZN\nOTHER TESTS\nScanning Label or Accession # (lab only)\nProvider(s)\n Patient\nCollection\nPHN\nExpiry: ________\nDate of Birth (dd-Mon-yyyy)\nLegal Last Name Legal First Name Middle Name\nAlternate\tIdentifier Preferred Name o Male o Female\no Non-binary o Prefer not to disclose\nPhone\nAddress City/Town Prov Postal Code\nAuthorizing Provider Name (last, first, middle) Copy to Name (last, first, middle) Copy to Name (last, first, middle)\nAddress Phone Address Address\nCC Provider ID CC Submitter ID Legacy ID Phone Phone\nClinic Name Clinic Name Clinic Name\nDate (dd-Mon-yyyy) Time (24 hr) Location Collector ID\n578788878\n1998-12-11\nKash\nDiv\nMequanent\nTed\n52 Castlefall Way NE\nCaglary\nChoose Province\nT3J1M7\n1"}...
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{"name": "labs-18c5dd82-c58b-4509-8934 {"name": "labs-18c5dd82-c58b-4509-8934-2a4a373487b6.pdf", "content_type": "application/octet-stream", "size": 1157055, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-6c2ccd95-f90e-4960-9561-a563ac1b28e1"}...
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{"status": "completed", "conte {"status": "completed", "content": "Referring Physician\nDate:\nPhysician Name:\nPhysician Address:\nPhysician ID:\nPhysician Signature:\nPatient Information\nPhysician Email:\nUrgency\n24 hrs 48 hrs 72 hrs 1 Week\n#250-8500 Blackfoot Trail SE\nCalgary, AB T2J 7E1\nTel: 403-879-7911\nwww.chestpainclinic.ca\nChest Pain Rating\n1 2 3 4 5 6 7 8 9 10\nMedical History \nCheck All That Apply\n Abnormal ECG\nAtrial Fibrillation\nAbnormal Coronary CT\nHistory of Myocardial Infarction\nHistory of Heart Failure\nPalpitation\nAdditional Information / Report Attached\n ECG Lab Stress Test Echo MPI\nCT MRI Holter 24ABP\nFax: 403-879-7899\n Angina Typical Atypical\n History of COPD\nAbnormal Stress Test\nShortness of Breath\nHistory of CABG \nHistory of Valvular Surgery\nObstructive Sleep Apnea\nX-Ray\n Diabetes\nHypertension\nHyperlipidemia\nK\nnown CAD\nSmoker Current Past\n Family History of Heart Disease Peripheral Artery Disease\nCONFIDENTIALITY STATEMENT: Information contained in this communication may be confidential and is intended only for the use of the recipient(s). If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, \ndistribution, or copying of this communication or any of its content is strictly prohibited. If you receive this communication or any of its contents in error please return it to the sender and contact Advanced Cardiology 403.235.4109\nPatient Name:\nPatient PHN Number:\nPatient Address:\nDate of Birth:\nPatient Phone:\nMale Female\n1998-12-11\n578788878"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n11-12-1998\n578788878\nDoe\n52 Castlefall Way NE\nCaglary\nT3J1M7\n52 Castelfall way NEasdasdasd\ncalgary\nt3j1m7\n(123) 456-7876\n123-434-5676\nChoose Province\nDr John"}...
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{"status": "completed", "conte {"status": "completed", "content": "Generic Referral \nDate (dd/Mon/yyyy) Refer to\nPatient Address Phone\nReferring Provider/Source Phone\nReferring Provider Address Fax\nFamily Physician\nLegal Guardian Name Phone Relationship\nEnsure referral meets specifi c referral requirements where these are \navailable. For more information on criteria and where to send the referral \nvisit: www.albertareferraldirectory.ca\nThis referral form could also be completed electronically within the Telus \nHealth and Accuro EMRs using the \"QuRE Consultation-Referral Request \nand Response\" template.\n19619 (Rev2020-01)\nWho has been informed of the reason for this referral? \uf06fPatient \uf06fGuardian \uf06fPatient and Guardian\nAdditional Patient Information \uf06fPatient has guardian \uf06fPatient has alternative contact\n\uf06fPatient unable to communicate well in English \uf06fPatient has vision requirements\n\uf06fPatient has hearing requirements \uf06fWCB claim\nSpecial Considerations \uf06fInterpreter required \uf06fPhysical limitations\n\uf06fSocial / Psychological \uf06fEconomic Details: ________________________________________\nReferral Information\nReason for referral \nType of Request \uf06fAdvice \uf06fConsult\nPriority of Referral \uf06fRoutine \uf06fUrgent \uf06fEmergent\nPatient's Current Status \uf06fStable \uf06fWorsening\nPatient Expectation\nFindings and/or investigations\nCurrent and Past Management\nMedical History\nActive Medications\nAllergies\nSurgical History\nFamily History\nInformation given to patient\nCompleted By\nName Signature Designation Date\n (dd/Mon/yyyy)\nLast Name (Legal) First Name (Legal)\nPreferred Name /box1 Last /box1 FirstDOB(dd-Mon-yyyy)\nPHN ULI /box1 Same as PHNMRN\nAdministrative Gender /box1 Male /box1Female\n/box1Non-binary/Prefer not to disclose (X)\nDylan Gentry\nQuibusdam qui magni\n26-Jan-2017\n1993-Oct-09\nFuga Magnam ad veli 11\nAtque exercitation d\nEos et vitae dolor u\nVoluptatum amet obc\nMaxime quod maiores\nAlias voluptas \nsed e\nEius ea quasi et com\nRerum ad omnis harum\n+1 (699) 921-8192\nConsectetur est ad\nVeniam qui qui est\nBeck\nGalena\nDicta velit rerum no\nNatus maxime debitis\nNihil \npraesentium op\n\u25a0\n\u25a0\n\u25a0\n\u25a0\n\u25a0\nDelectus dignissimo\nVoluptate non sit pl\nConsequatur do sunt\nRerum magni consequa\nId id et sit eiusmod\nEum rem adipisicing\nVoluptas temporibus\nUt libero adipisci q\nProident ullam volu\nEt officiis laborum\nDucimus dolor qui e\nIn voluptas \nex ex re\nVoluptatibus \nvolupta"}...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\nMALE FEMALE\n\u25a0\n\u25a0\n\u25a0\nLovpreet Mangat\n3151 27 St NE #201, Calgary, T1Y7J8, AB\n(403) 235-4109\nDiv Kash\n666777888\n52 Castlefall Way NE, Caglary, T3J1M7, AB\n15879987876\n\u25a0\n\u25a0\n12-Dec-2025\n13-Nov-2025"}...
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{"status": "completed", "conte {"status": "completed", "content": "Advanced Cardiology Consultants & Diagnostic Inc\n#250 8500 Blackfoot Trail SE\nCalgary, AB, T2J7E1\nTel: 403-879-7911 | Fax 403-879-7899\nNUCLEAR MYOCARDIAL PERFUSION IMAGING EXERCISE STRESS STUDY\nDecember 11, 2025 Chart No: A43819\nRef. Dr.: Dr. Ali Debek Family Dr.:\nRE: Div Kash Supervising MD:Dr. Daniel Anselm\nPHN: 666777888 Technologist:\nDOB: 12 December, 2025 Gender: Female\nClinical History:Z\n- Chest Pain\nECG Information Resting ECG: zx - Horizontal ST changes in the Inferolateral Lead\nExercise Stress Test Information\nInterpretation by: Dr. Daniel Anselm Stress Interpretation ECG:\nProtocol: Symptoms During Test: METS achieved:\nPeak HR: zxzxz Peak HR % Achieved: Exercise Duration:\nReason of Termination: zx Protocol completed\nStage Heart Rate (bpm) Blood Pressure\nRest\n1 zx\n2\n3\n4\n5\nRecovery\nMPI Technique:\nMbq of 99m Tc-Tetrofosmin was administered intravenously at rest and\nMbq of 99m Tc-Tetrofosmin was administered intravenously at peak stress following Exercise Myocardial Perfusion.\nMultiple gated tomographic emission images were obtained post stress and at rest. These images were reconstructing\ninto short axis, vertical long axis and horizontal long axis planes.\nImage quality:\nFindings:\nThere is normal myocardial perfusion. No fixed or reversible perfusion abnormalities are identified.\nThe left ventricle is normal in size. All left ventricular segments thicken and contract normally. The left ventricular ejection\nfraction is >50% post stress and >50% at rest. There is no visual evidence of TID.\nImpression:\nNormal myocardial perfusion and left ventricular systolic function.\nMPI Interpreting Physician: Ramu Report Date: December 11, 2025\nInformation contained in this communication may be confidential and is intended only for the use of the recipient(s). If the reader of this\nmessage is not the intended recipient, you are hereby notified that any dissemination, distribution, or copying of this communication or any\nof its contents is strictly prohibited. If you received this communication in error please return it to the sender and contact Advanced\nCardiology on 403-8797899 .\nName: Div Kash | PHN: 666777888 | DOB: 12 Dec, 2025 Page 1 Of 1"}...
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{"status": "completed", "conte {"status": "completed", "content": "Carlos Flores tejeda (A81728) DOB: 23 Oct 1983 Age: 41\nPrinted by Super Admin, 2025 at 09 Oct, 2025 10:24:35 AM Page: 1 Date\n03\nOct\n2025\nChart\nNote:\nBP Heart\nRate\n(bpm)\nHeight\n(cm) \n0\nWeight\n(kg) 0\nBMI\n(kg/m^2)\n0,\nComplaint Past\nMedical\nHistory:\nMOA \nCardiac\nRisk\nFactor:\nMOA \nPhysical\nExamination\nSurgical\nHistory \nECG Allergies\nto\nMedication\nPlan: Full\nconsult\ncompleted. In\nbrief this is a\n41-year-old man\nwith no\nsignificant past\nmedical history.\nNo history of\nCHF no history\nof hypertension\nno history of\ndiabetes no\nhistory of\nvascular\ndisease no\nhistory of stroke\nor TIA. He is\ncompletely\nwithout any past\nmedical history.\nHe was found to\nhave new onset\natrial fibrillation\nand currently is\non bisoprolol\nand aspirin. His\nonly complaint\nis dyspnea on\nexertion. No\nlonger chest\npain.\nOccasional\npalpitations. No\northopnea no\nPND no\nperipheral\nedema. He\ndoes not\nsmoke. No illicit\ndrug use. No\nalcohol use No\nfamily history of\npremature heart\ndisease or\nsudden cardiac\ndeath No known\ndrug allergies\nCurrent\nmedications:\nBisoprolol\naspirin Blood\npressure 116/78\nheart rate 76,\nsaturating 97%\non room air\nLungs clear to\nauscultation\nHeart normal\nS1-S2 regular\nrate and\nrhythm. No\nperipheral\nedema\nEchocardiogram\nnormal ejection\nfraction no\nregional wall\nmotion\nabnormalities.\nNo severe\nvalvular\npathology\nExercise stress\ntest: Patient\ncompleted 7\nminutes and 48\nseconds of\nBruce protocol.\nAchieving a\ntotal of 10.2\nMETS workload\nload. No chest\npain. Normal\nblood pressure\nresponse. No\nsignificant\narrhythmias.\nThis was a\nnondiagnostic\nstress test due\nto baseline ST-\nT changes\nNonspecific\ndyspnea on\nexertion. Within\nnondiagnostic\nstress test. I will\narrange an\nexercise MPI.\nHe is with new\nonset atrial\nfibrillation\ncurrently today\nwas in sinus\nrhythm. And\nrate controlled. I\nwill continue\nwith aspirin and\nbisoprolol. His\nchads vascular\n2 score is 0. I\nwill get a 24-\nhour amatory\nblood pressure\nmonitor as well.\nAnd he will\nfollow-up with\nhis primary\ncardiologist\nFollow-\nup: Dr.\nMangat\nDictations\nare not\nworking\ntoday "}...
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{"name": "labs-1762968153-form-flatten {"name": "labs-1762968153-form-flattened-2025-11-12t17-22-32-115z.pdf", "content_type": "application/octet-stream", "size": 1950193, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-173371aa-19c2-494f-be28-2016863a83ec"}...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\nMALE FEMALE\n\u25a0\n\u25a0\n\u25a0\nRavi Varshney\n3151 27 St NE #201, Calgary, T1Y 0B4, AB\n(403) 235-4109\nDiv Kash\n666777888\n52 Castlefall Way NE, Caglary, T3J1M7, AB\n15879987876\n\u25a0\n12-Dec-2025\n12-Nov-2025"}...
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{"name": "labs-1762809830-form-flatten {"name": "labs-1762809830-form-flattened-2025-11-10t21-23-50-051z.pdf", "content_type": "application/octet-stream", "size": 1950085, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-75f12d1b-1d0a-4063-9a54-53c35682194d"}...
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83622476a4660491a467eb0d2c0ef3fef1f17231847ffd4233 83622476a4660491a467eb0d2c0ef3fef1f17231847ffd4233d1492ce6f05578...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\nMALE FEMALE\n\u25a0\n\u25a0\n\u25a0\n1515\nRavi Varshney\n8500 Blackfoot Trl SE #250, Calgary, T2J 7E1, AB\n(403) 879-7911\nDiv Kash\n666777888\n52 Castlefall Way NE, Caglary, T3J1M7, AB\n15879987876\n\u25a0\n\u25a0\n\u25a0\n\u25a0\n12-Dec-2025\n10-Nov-2025"}...
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{"name": "labs-1761336536-form-flatten {"name": "labs-1761336536-form-flattened-2025-10-24t20-08-56-361z.pdf", "content_type": "application/octet-stream", "size": 1950247, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-2d42ed88-c7a5-4cba-9cd4-4e6437d5736b"}...
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2dde7cc8c0ff13f19d77ec9b3e3f69d6f4f881e944a6bc5a8b 2dde7cc8c0ff13f19d77ec9b3e3f69d6f4f881e944a6bc5a8bd775d4c0389e54...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\nMALE FEMALE\n\u25a0\n\u25a0\nSulaiman Alnasser\n3151 27 St NE #201, Calgary, AB T1Y 7J8, Alberta\n(403) 235-4109\nDiv Kash\n666777888\n52 Castlefall Way NE, Caglary, T3J1M7, AB\n15879987876\n\u25a0\n12-Dec-2025\n24-Oct-2025"}...
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{"name": "labs-1760462428-form-flatten {"name": "labs-1760462428-form-flattened-2025-10-14t17-20-27-646z.pdf", "content_type": "application/octet-stream", "size": 1950207, "data": {"patient_id": "b3e7cc30-1ba8-11f0-b706-c183bb9a9165"}, "collection_name": "file-bf6c221c-cd14-460f-8913-a0ab218bcc7e"}...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\nMALE FEMALE\nLovpreet Mangat\n3151 27 St NE #201, Calgary, T1Y7J8, AB\n(403) 235-4109\nDiv Kash\n666777888\n52 Castlefall Way NE, Caglary, T3J1M7, AB\n15879987876\n\u25a0\n12-Dec-2025\n14-Oct-2025"}...
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{"name": "labs-1751116458-form-flatten {"name": "labs-1751116458-form-flattened-2025-06-28t13-14-16-809z.pdf", "content_type": "application/octet-stream", "size": 1954980, "data": {"patient_id": "c58c79c0-48e6-11f0-bb4c-4706231f1026"}, "collection_name": "file-74fc6d6a-a017-4a5a-a132-047431db9cd1"}...
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1be5f095529355d0f1614bd3377be00e4b1333be53f25ed34e 1be5f095529355d0f1614bd3377be00e4b1333be53f25ed34eee58ffd1e7891b...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\n\u2714\n\u2714\nHello testing\n\u2714\nABCD EDF\n\u2714\n\u2714\n\u2714\n\u2714\n\u2714\n\u2714\n\u2714\n\u2714\n, , , \n28-06-2025\nDiv Kash Kash\n, , , AB\n21-12-2000\n\u2714\n\u2714\n\u2714\n\u2714\n\u2714\n\u2714\n20.00\n18.00\n\u2714\n\u2714"}...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\nhello doctors\nTesting\nABCD EDF\n, , , \n28-06-2025\nDiv Kash Kash\n, , , AB\n21-12-2000\n\u2714\nnejfne fejnfwe"}...
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{"name": "labs-1751096541-form-flatten {"name": "labs-1751096541-form-flattened-2025-06-28t07-42-19-504z.pdf", "content_type": "application/octet-stream", "size": 1971076, "data": {"patient_id": "c58c79c0-48e6-11f0-bb4c-4706231f1026"}, "collection_name": "file-c8b50485-46ab-4386-9f97-595ef0b1453c"}...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\nhello doctors\nTesting\nABCD EDF\n, , , \n28-06-2025\nDiv Kash Kash\n, , , AB\n21-12-2000\n\u2714\nnejfne fejnfwef"}...
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{"name": "labs-1751096541-form-flatten {"name": "labs-1751096541-form-flattened-2025-06-28t07-42-19-487z.pdf", "content_type": "application/octet-stream", "size": 1971065, "data": {"patient_id": "c58c79c0-48e6-11f0-bb4c-4706231f1026"}, "collection_name": "file-bdf37498-3c67-42e1-b432-f66feffb2233"}...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\nhello doctors\nTesting\nABCD EDF\n, , , \n28-06-2025\nDiv Kash Kash\n, , , AB\n21-12-2000\n\u2714\nnejfne fejnfwef"}...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\nhello doctors\nTesting\nABCD EDF\n, , , \n28-06-2025\nDiv Kash Kash\n, , , AB\n21-12-2000\n\u2714\nnejfne fejnfwef"}...
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/home/sid/xevyo/open-webui-dev/backend/data/upload /home/sid/xevyo/open-webui-dev/backend/data/uploads/e3e1c5f5-d585-469a-a99b-16b7575349a4_labs-1751096541-form-flattened-2025-06-28t07-42-19-477z.pdf...
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labs-1751096541-form-flattened-2025-06-28t07-42-19 labs-1751096541-form-flattened-2025-06-28t07-42-19-417z.pdf...
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{"name": "labs-1751096541-form-flatten {"name": "labs-1751096541-form-flattened-2025-06-28t07-42-19-417z.pdf", "content_type": "application/octet-stream", "size": 1971084, "data": {"patient_id": "c58c79c0-48e6-11f0-bb4c-4706231f1026"}, "collection_name": "file-b6d01002-7fd5-4521-86d5-ea149efcf5a2"}...
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dc281613133600fe09bf8d925737dee7afe25c68b625ea4989 dc281613133600fe09bf8d925737dee7afe25c68b625ea4989586a505565539b...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\nhello doctors\nTesting\nABCD EDF\n, , , \n28-06-2025\nDiv Kash Kash\n, , , AB\n21-12-2000\n\u2714\nnejfne fejnfwef"}...
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labs-1751040884-form-flattened-2025-06-27t16-14-42 labs-1751040884-form-flattened-2025-06-27t16-14-42-008z.pdf...
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{"name": "labs-1751040884-form-flatten {"name": "labs-1751040884-form-flattened-2025-06-27t16-14-42-008z.pdf", "content_type": "application/octet-stream", "size": 1970374, "data": {"patient_id": "c58c79c0-48e6-11f0-bb4c-4706231f1026"}, "collection_name": "file-11bf024b-14bd-4871-96c8-1021a8c8fcb7"}...
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468f6b104ad64f10edd8a351c3dbb662610424cbb163c43ede 468f6b104ad64f10edd8a351c3dbb662610424cbb163c43edee176a9f146ed3d...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\n, , , \n27-06-2025\nDiv Kash Kash\n, , , AB\n21-12-2000"}...
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1772234595
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labs-1751040848-form-flattened-2025-06-27t16-13-52 labs-1751040848-form-flattened-2025-06-27t16-13-52-777z.pdf...
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{"name": "labs-1751040848-form-flatten {"name": "labs-1751040848-form-flattened-2025-06-27t16-13-52-777z.pdf", "content_type": "application/octet-stream", "size": 1967195, "data": {"patient_id": "c58c79c0-48e6-11f0-bb4c-4706231f1026"}, "collection_name": "file-46ac9f3e-d4f0-49c0-9862-578116ef6239"}...
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d3da16d5224dc17c67a9d9d0e48972659611e47489e63a5457 d3da16d5224dc17c67a9d9d0e48972659611e47489e63a54577d3001b2d0bd89...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\n\u2714\nHello testing\nHello hello\n\u2714\n\u2714\n, , , \n27-06-2025\nDiv Kash Kash\n, , , AB\n21-12-2000\nrefrf"}...
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{"name": "labs-1751040500-form-flatten {"name": "labs-1751040500-form-flattened-2025-06-27t16-08-17-436z.pdf", "content_type": "application/octet-stream", "size": 1967174, "data": {"patient_id": "c58c79c0-48e6-11f0-bb4c-4706231f1026"}, "collection_name": "file-eff67a6c-d805-4cc7-bef0-b208d0df39c3"}...
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d3da16d5224dc17c67a9d9d0e48972659611e47489e63a5457 d3da16d5224dc17c67a9d9d0e48972659611e47489e63a54577d3001b2d0bd89...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\n\u2714\nHello testing\nHello hello\n\u2714\n\u2714\n, , , \n27-06-2025\nDiv Kash Kash\n, , , AB\n21-12-2000\nrefrf"}...
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72d193c0-547b-40e0-9e7a-8689f1ae66a3
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labs-1751040499-form-flattened-2025-06-27t16-08-17 labs-1751040499-form-flattened-2025-06-27t16-08-17-664z.pdf...
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{"name": "labs-1751040499-form-flatten {"name": "labs-1751040499-form-flattened-2025-06-27t16-08-17-664z.pdf", "content_type": "application/octet-stream", "size": 1967179, "data": {"patient_id": "c58c79c0-48e6-11f0-bb4c-4706231f1026"}, "collection_name": "file-72d193c0-547b-40e0-9e7a-8689f1ae66a3"}...
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d3da16d5224dc17c67a9d9d0e48972659611e47489e63a5457 d3da16d5224dc17c67a9d9d0e48972659611e47489e63a54577d3001b2d0bd89...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\n\u2714\nHello testing\nHello hello\n\u2714\n\u2714\n, , , \n27-06-2025\nDiv Kash Kash\n, , , AB\n21-12-2000\nrefrf"}...
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/home/sid/xevyo/open-webui-dev/backend/data/upload /home/sid/xevyo/open-webui-dev/backend/data/uploads/72d193c0-547b-40e0-9e7a-8689f1ae66a3_labs-1751040499-form-flattened-2025-06-27t16-08-17-664z.pdf...
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d0a79849-a3b5-4253-ac0e-e8cd98889292
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labs-1751040048-form-flattened-2025-06-27t16-00-44 labs-1751040048-form-flattened-2025-06-27t16-00-44-381z.pdf...
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{"name": "labs-1751040048-form-flatten {"name": "labs-1751040048-form-flattened-2025-06-27t16-00-44-381z.pdf", "content_type": "application/octet-stream", "size": 1964696, "data": {"patient_id": "c58c79c0-48e6-11f0-bb4c-4706231f1026"}, "collection_name": "file-d0a79849-a3b5-4253-ac0e-e8cd98889292"}...
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6e849dbd8e7d972ee4baeddc5dbfa13a14a4379e04fd0fb198 6e849dbd8e7d972ee4baeddc5dbfa13a14a4379e04fd0fb198c4a869202b216d...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\nHello testing\n\u2714\n\u2714\ntesting\n\u2714\n\u2714\n\u2714\n, , , \n27-06-2025\nDiv Kash Kash\n, , , AB\n21-12-2000\n\u2714\n\u2714\n20.00\n50.00"}...
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labs-1751039969-form-flattened-2025-06-27t15-59-27 labs-1751039969-form-flattened-2025-06-27t15-59-27-568z.pdf...
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{"name": "labs-1751039969-form-flatten {"name": "labs-1751039969-form-flattened-2025-06-27t15-59-27-568z.pdf", "content_type": "application/octet-stream", "size": 1964713, "data": {"patient_id": "c58c79c0-48e6-11f0-bb4c-4706231f1026"}, "collection_name": "file-b1cb3b63-7997-4028-b48b-7c32e1170978"}...
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f1510749d7d78fba180f876db2cd7916c3731531e4b7e96f6c f1510749d7d78fba180f876db2cd7916c3731531e4b7e96f6c0a333d7b5ffe7e...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\nHello testing\n\u2714\n\u2714\ntesting\n\u2714\n\u2714\n\u2714\n, , , \n27-06-2025\nDiv Kash Kash\n, , , AB\n21-12-2000\n\u2714\n20.00\n50.00"}...
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{"name": "labs-1751039936-form-flatten {"name": "labs-1751039936-form-flattened-2025-06-27t15-58-53-722z.pdf", "content_type": "application/octet-stream", "size": 1975694, "data": {"patient_id": "c58c79c0-48e6-11f0-bb4c-4706231f1026"}, "collection_name": "file-8ae66102-93b3-4d32-beb5-87e3f866718e"}...
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{"status": "completed", "conte {"status": "completed", "content": "Please fax recent lab\n invesgaons, including Lipids,\nECG and Medica on List.\n \nDate:_________________________________________\nPhysician name:_________________________________\nPhysician address:_______________________________\nPhysician number:_______________________________\nPhysician signature:______________________________\nConsidered a valid prescripon when signed by a physician\nCopies to:_____________________________________ _\n250, 8500 Blackfoot Trail SE\nCalgary, AB T1Y 0B4\nT 403.879.7911\nF 403.879.7899\n201, 3151 27thStreet NE \nCalgary, AB T1Y 0B4\nT 403.235.4109 \nF 403.235.4147\nInternal Medicine\nEndocrinology\n\u2751Geriatric Medicine\nPaent Informaon Referring Physician\nConsultaon Requested:\n\u2751Cardiology\n\u2751\n\u2751\nMD, FCCP Internal Medicine\nMD, FACP Internal Medicine\nMD, FRCPC Cardiologist\nDr. Ravi Varshney\nDr. Lovpreet Mangat\nMD, FRCPC Internal Medicine\nDr. Faisal Hasan\nMD, MRCP Endocrinologist\n\u2751\n\u2751\n\u2751\nDr. Anmol Kapoor\nMD FRCPC Cardiologist\nDr. Alvin Villanueva\nDr. Ali Debek\n\u2751\n\u2751\n\u2751\nConsult\nUrgent (within 2 weeks) Semi-Urgent (more than 2 weeks) Phone Consult \u2013 Call 403.235.4109 to request\u2751 \u2751\u2751 \u2751ASAP\nPaent Like hood of CAD:\n \n(Plaque presence, caro d inmal medial thickness)\n) \nStroke / TIA\nFollow-up of known carod stenosis\nfollow-up\nPCOS\nHypo / Hyper Thyroid\nHirsusm/Amenorrhoea\nAdrenal Disorder\nAbnormal ECG\nPost PCI\nAbnormal Treadmill Stress Test\nMurmur\nShortness of breath\nHypertension / Le ventricular Hypertrophy\nPulmonary HypertensionIntermediate High\nCardiac Diagnosc Examinaon\nMyocardial Perfusion Imaging\n(MPI\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nExercise MPI\u2751\n\u2751Pharmacological MPI\nDoes Your Paent Have:\nMedicaon:\nCAD / CHF\nF/U Known Stable CAD\nFunconal Significance Coronary Stenosis\nChest Pain\nPalpitaons / Arrhythmias \n(suspected/known history of arrhythmia)\nEdema / PND / Orthopnea\nCardiovascular risk assessment\nSyncope / Presyncope / Vergo / Dizziness\nCarod Bruit\nPost-surgical angiographic intervenon \nLow Testosterone\nYoung Type 2 Diabetes\nPituitary Disorder\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n Please Check all that apply:Indicaons:\n(Includes Cardiology Consult)\n\u2751\n\u2751 Diabetes Type 2/Complex\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\n\u2751\nBubble Echocardiogram\n(Includes Cardiology consult)\nEchocardiogram \nCarod ultrasound\nExercise Stress Test\n(Includes Cardiology Consult)\n24 Hour Holter Monitor\n\u275148 Hour Holter Monitor\n5 day Holter Monitor\n\u2751ECG \u2013 Electrocardiogram\n24 hour BP Monitor\n\u2751ABI (Ankle Brachial Index)\n\u2751\nLow\n.\nwww.advancedcardiology.caPlease fax completed form - we will call the paent to book\nClinical Notes:\n \nHeight___cm/in Weight___lb/kg \nYes No\nNo\nNo\nNo\nNo\nYes\nYes\nYes\nYes\nDiabetes\nAsthma\nPacemaker\nICD\nCABG\nUrgency\nReferral\n\u2751Stress Echocardiogram\n(Includes Cardiology Consult)\n\u2714\nwee rfrfrfv\nwef\ngrgergs\nrregerg\ngregreger\nHello hello\n, , , \n27-06-2025\nDiv Kash Kash\n, , , AB\n21-12-2000\n\u2714\n\u2714\n15.00\n18.00"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nWhite\n52 Castlefall Way NE\nCaglary\nT3J1M7\nCalgary\n4032354147\nChoose Province\nDavid"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10) \nKash\nDiv\n1998-12-11\n578788878\nMequanent\n52 Castlefall Way NE\nCaglary\nT3J1M7\ncalgary\nT1Y6L4\n1\n4036481926\nChoose Province\nTed"}...
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{"status": "completed", "conte {"status": "completed", "content": "ABATACEPT for Polyarticular Juvenile \nIdiopathic Arthritis \nSPECIAL AUTHORIZATION REQUEST FORM \nPlease complete all required sections to allow your request to be processed. Patients may or may not meet eligibility requirements as established \nby Alberta Government sponsored drug programs. \nPATIENT INFORMATION COVERAGE TYPE\nPATIENT LAST NAME FIRST NAME INITIAL\n Alberta Blue Cross \n Alberta Human Services \n Other\nDATE OF BIRTH: YYYY/MM/DD ALBERTA PERSONAL HEALTH NUMBER\nSTREET ADDRESS CITY PROV POSTAL CODE ID /CLIENT/COVERAGE N UMBER \nPRESCRIBER INFORMATION \nPRESCRIBER LAST NAME FIRST NAME INITIAL PRESCRIBER PROFESSIONAL ASSOCIATION REGISTRATION \n CPSA \n CARNA \n ACP \n ACO \n ADA+C \n Other \nREGISTRATION NUMBER \nSTREET ADDRESS \nPHONE FAX \nCITY, PROVINCE \nPOSTAL CODE FAX NUMBER MUST BE PROVIDED WITH EACH REQUEST SUBMITTED \nPlease provide the following information for ALL requests \nDiagnosis \n Polyarticular Juvenile Idiopathic Arthritis \n Other ( please specify) ______________________ \nCurrent weight (kg) Dosage \nDosing frequency \nPlease provide reason if a switch from a different biologic agent to abatacept is requested \nNote: Patients will not be permitted to switch back to a previously trialed biologic agent if they were deemed unresponsive to ther apy \nCurrent ACR Pedi 30 FLARE score (provide for ALL requests) \nACR Pedi 30 RESPONSE score at 16 to 20 weeks after first dose \nof previous abatacept treatment (provide for RETREATMENT \nrequests) \nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________ w\nith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. No\n. of active joints* ___________ 6. ESR (mm/hr) ____ ______\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nDate of assessment___________________________ \n1. R\nheumatologist global 4. No. of joints\na\nssessment (0-10) ___________\nwith LROM ___________ \n2. P\natient global 5. CHA\nQ (0-3) ___________\nassessment (0-10) ___________\n3. N\no. of active joints* ___________ 6. ESR (mm/hr) _____ _____\n or CRP ______________\n*joints with swelling not due to deformity or joints with limitation of motion with pain,\ntenderness or both\nPlease provide the following information for ALL NEW requests \nPrevious medications utilized: Dose, duration and response is required \n DMARD(s) (please specify agents) \n Adalimumab\n Etanercept \n Tocilizumab \n Other (please specify agent) \nAdditional information relating to request (e.g. reasons why any of the above therapies were not tried) \nPRESCRIBER'S SIGNATURE DATE Please forward this request to \nAlberta Blue Cross, Clinical Drug Services \n10009 108 Street NW, Edmonton, Alberta T5J 3C5 \nFAX: 780 498-8384 in Edmonton \u2022 1-877-828-4106 toll free all other areas \nONCE YOUR REQUEST HAS SUCCESSFULLY TRANSMITTED, PLEASE DO NOT MAIL OR RE-FAX YOUR REQUEST \nThe information on this form is being collected and pursuant to sections 20, 21 and 22 of the Health Information Act, and sec tions 33 and 34 of the Freedom of Information and \nProtection of Privacy Act, for the purposes of determining or verifying eligibility to participate in a program or receive a benefit, product or health service. If you have any questions \nregarding the collection or use of this information, please contact an Alberta Blue Cross privacy matters representative toll -free at 1-855-498-7302 or write to Privacy Matters, \nAlberta Blue Cross, 10009 108 Street, Edmonton AB T5J 3C5. \n \u00ae*The Blue Cross symbol and name are registered marks of the Canadian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC \nBenefits Corporation for use in operating the Alberta Blue Cross Plan. \u00ae\u2020 Blue Shield is a registered trade- mark of the Blue Cross Blue Shield Association. \nABC 60010 (2016/10)"}...
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