THE AW MORROW GASTROENTEROLOGY & LIVER CENTRE
ROYAL PRINCE ALFRED HOSPITAL
ANTENATAL HCV REFERRAL FORM

PLEASE FAX OR DELIVER 

PATIENT LABEL	
COMPLETED REFERRAL TO
HEPATITIS C CNC or Named Specialist				
FAX: 9515 5182	
TEL: 9515 7049

Referring Medical Officer:
<DrName>

Contact:<DrPhone>
	Patient Contact Details:

Name: <PtName>

Mobile: <PtPhoneMob>
Home: <PtPhoneH>
Work:<PtPhoneWk>	

Date of Referral:<TodaysDate>	
Gestational Time:	

HCV Antibody Test indicates past exposure to Hepatitis C.
HCV PCR Test detects current Hepatitis C virus in the blood.	

Blood Results
* HCV Antibody: ________ Date of Test:_____             
* HCV PCR: ____________ Date of Test: ______
*Please ensure both tests have been attended prior to referral*	

Person Completing Form

Name: ____________________

Signed: ___________________	
GP Details

Name: <DrName>

Address:<Practice> <DrAddress>

Contact: <DrPhone>	

Patient Consent

I understand this information will be faxed to the liver clinic nurses for review and that they will make contact with me to discuss the results.

Patient Signed: ____________________Date: <TodaysDate>