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METAVIR score Fibroscan score Ishak score Radiological imaging Date of test FibroSURE score APRI score Note this form continues onto a second page incomplete forms cannot be processed CONTINUED ON NEXT PAGE Created 07/13/2016 Reviewed/Revised 09/12/2016 Page 1 of 2 HPHC Medication Request Form - Epclusa 3/27/2017 12 28 PM If yes is it compensated or decompensated cirrhosis compensated Child-Turcotte-Pugh Class A no major complications of cirrhosis hemorrhage spontaneous bacterial peritonitis...
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