Liver ToolKit Project – Referral to Royal Prince Alfred 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? 
ATSI: <<Patient Demographics:ATSI>>

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 [   ]

Has the patient previously seen a gastroenterologist/hepatologist – if yes who?

Please attach the following
A summary of this patient’s medical conditions and current medications [   ]
Recent blood tests – including FBC, UEC, LFTs, Coags, AFP [   ]
Fibroscan result if available [   ]
Any previous testing for hepatitis B and C [   ]
Any previous liver imaging – liver ultrasound or abdominal CT [   ]

Send all referrals electronically via HealthLink to the clinic EDI: awmorrow

*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 David Prince – 9515 8578

Medications
<<Clinical Details:Medication List>>

Past Medical History
<<Clinical Details:History List>>

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