THE AW MORROW GASTROENTEROLOGY & LIVER CENTRE
ROYAL PRINCE ALFRED HOSPITAL
HCV PRE TREATMENT ONLY FIBROSCAN REFERRAL FORM
FOR GP OR REMOTE PRESCRIBING
Please fax or deliver completed form to Gastro and Liver Ambulatory Care
Fax. 	9515 8242
Tel. 	9515 7268	Source of Referral	
REFERRAL TO
(please tick)	

* GP
* Rooms
* Clinic / Outpatients
* Ward: ..............
* Other  .......................	
Fibroscan Only                ☐
Results will be faxed back to GP or referrer. Results are not reviewed by a hepatologist. If you would like results reviewed be a hepatologist please refer patient to a hepatologist.	

Date of 
Procedure:                        Time:	MRN	Patient Title
<<Patient Demographics:Title>>	
Family Name
<<Patient Demographics:Surname>>	Given Name(s)
<<Patient Demographics:First Name>>	Date of Birth
<<Patient Demographics:DOB>>	Sex
<<Patient Demographics:Sex>>	
Residential Address
<<Patient Demographics:Full Address>>	Telephone	

Home: <<Patient Demographics:Phone (Home)>>
Work: <<Patient Demographics:Phone (Work)>>
Mobile: <<Patient Demographics:Phone (Mobile)>>	

Medicare Number	<<Patient Demographics:Medicare Number>>			Expiry Date	<<Patient Demographics:Medicare Expiry Date>>	
Referring Doctor or Nurse
Name:<<Doctor:Name>>		
Address:<<Doctor:Full Address>>	
Fax number to receive fibroscan report:      <<Doctor:Fax>>          Phone:<<Doctor:Phone>>	
Referral Date: 	<<Miscellaneous:Date>>     Provider No.: <<Doctor:Provider Number>>       Signature: 	
Clinical History/HCV Treatment Plan		
Blood result
(recent)	
Date:................ALT Level :....................Platelet Count:.......................................................	
Previous Liver Biopsy or Fibroscan	Date: ...................................................		Fibrosis Stage/Fibroscan Score:...................................		
Any other Causes of Liver Disease?   	Specify:	
Comment:	

	

Preparation         NIL BY MOUTH 3 HOURS 	
If GP is not the referrer should report be faxed to GP       Yes *    No *	If yes, Please provide:
GP Name:............................................................................................
Fax No:................................................................................................	
If your patient is found to have a Fibroscan score ≥ 12.5 kPa (indicates cirrhosis) please refer to a specialist (see Liver Condition Assessment HealthPathways)
If you want a Fibroscan for a purpose other than HCV pre treatment assessment please refer for a medical or nurse (if HBV) consultation (see Liver Condition Assessment HealthPathways)                                                                            July 2015