Dr. Michael Wang

Other Conditions

Last known eGFR(*)

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Family history of ADPKD(*)

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Family history of dialysis/transplant(*)

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Relative's age at dialysis/transplant(*)

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Current ADPKD therapy

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Consultant's name

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Consultant's Fax

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Patient first name

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Patient last name

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Patient date of birth

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Patient insurance # (e.g. OHIP)

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Patient phone number

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Request for ADPKD Consultation

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Referring doctor name

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Fill out patient demographic information on the left or place address label here

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Patient information

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