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:
<<Doctor:Name>>

Contact:<<Doctor:Phone>>
	Patient Contact Details:

Home: <<Patient Demographics:Full Name>>

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

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

Date of Referral:<<Miscellaneous:Date>>	
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: <<Doctor:Name>>

Address:<<Practice:Name>> <<Doctor:Full Address>>

Contact: <<Practice:Phone>>	

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: <<Miscellaneous:Date>>