Liver ToolKit Project – Referral to St George Hospital Liver Clinic

Patient Details
Name: <<Patient Demographics:Full Name>> 
Date of Birth: <<Patient Demographics:DOB>>
Medicare number: <<Patient Demographics:Medicare Number>>
Address:  <<Patient Demographics:Address>>
Mobile #: <<Patient Demographics:Phone (Mobile)>>
Is an interpreter required (Y/N) – If yes, which language?
Aboriginal or Torres Strait Islander (Y/N)

Referring Doctor Details
Practice Name: <<Practice:Name>>
Practice Address: <<Practice:Address>> 
Practice Fax #: <<Practice:Fax>>
Referring Doctor:  <<Doctor:Name>>
Provider #: <<Doctor:Provider Number>>

What is the patient’s underlying liver condition? (Can tick more than one)
Hepatitis B virus [  ] 
Hepatitis C virus [  ]
NAFLD [  ]
Alcohol related [  ]
Other [   ]
Unknown [   ]

Please tick which of the following are applicable
Patient identified via liver toolkit program* [  ]
Patient has cirrhosis [  ]
Patient has liver cancer [   ]

Please answer the following:
Has the patient been seen previously by a gastroenterologist or hepatologist? [Y/N] If yes, please advise their name: ______________  

Important: Please Read
Please attach a summary of this patient’s medical conditions and current medications. Please attach all relevant investigations (ie HBV, HCV serology) including most recent liver ultrasound, Fibroscan and pathology. Send all referrals electronically via HealthLink to the clinic EDI: stgliver

*Please note this referral form is for patients who are identified via the Liver ToolKit Project only. Any inquires in relation to the Liver ToolKit Project are to be directed to Dr Salim Maher – Clinical Research Fellow in Hepatology at 9113 3111.

Medications: 
<<Clinical Details:Medication List>>

History:
<<Clinical Details:History List>>

Relevant Investigations: 
<<Summary:Investigation Results (Selected)>>