FOR ATTENTION OF:  DR                                                   		Date:    <<Miscellaneous:Date>>              
Please note this form is not a referral for a patient appointment.
Note: GPs are eligible to prescribe Hepatitis C treatment under the PBS, provided it is done in consultation with a gastroenterologist, hepatologist or infectious disease physician experienced in the treatment of chronic Hepatitis C infection.
GP name	<<Doctor:Name>>	
GP suburb		GP postcode	<<Doctor:Postcode>>	
GP phone	<<Doctor:Phone>>	GP fax	<<Doctor:Fax>>	
GP mobile phone		
GP email address	<<Doctor:E-mail>>	

Patient name	<<Patient Demographics:Full Name>>	
Patient date of birth	<<Patient Demographics:DOB>>                        	
Patient residential postcode	<<Patient Demographics:Address Preferred Postcode>>	

Hepatitis C History

Date of HCV diagnosis:                     

Known cirrhosis*	☐ Yes	☐ No
* Patients with cirrhosis or HBV/HIV coinfection should 
be referred to a specialist	Intercurrent Conditions
Diabetes	
☐ Yes	
☐ No	

Obesity	
☐ Yes	
☐ No	

Hepatitis B	
☐ Yes	
☐ No	

HIV 	
☐ Yes	
☐ No	

Alcohol > 40 g/day	
☐ Yes	
☐ No	

Discussion re contraception	
☐ Yes	
☐ No	

	
Prior Antiviral Treatment	

Has patient previously received any antiviral treatment?	
☐ Yes	☐ No	

Has prior treatment included oral antiviral therapy?	
☐ Yes	☐ No	

Prior treatment?_______________
I have checked for potential 
drug–drug interactions with current medications†	
☐ Yes	☐ No	

	Current Medications
(Prescription, herbal, OTC, recreational)

	

† http://www.hep-druginteractions.org 
If possible, print and fax a PDF from this site showing you have checked drug–drug interactions.	

Laboratory Results (or attach copy of results)	
Test	Date	Result	Test	Date	Result	
HCV genotype	               		Creatinine	               		
HCV RNA level	      		eGFR	               		
ALT	               		Haemoglobin	           		
AST	               		Platelet count	             		
Bilirubin	              		INR	           		
Albumin	          		HBsAg			

Liver Fibrosis Assessment**	
Test	Date	Result	
FibroScan	               		
Other (eg. APRI)	              		
APRI: http://www.hepatitisc.uw.edu/page/clinical-calculators/apri
** People with liver stiffness on FibroScan of ³ 12.5 kPa or an APRI score ≥ 1.0 may have cirrhosis and should be referred to a specialist.	
Treatment Choice
I plan to prescribe (please select one):
Regimen	Duration	Genotypes	
Sofosbuvir / Velpatasvir	
12 weeks   ☐	
1, 2, 3, 4, 5, 6	
Sofosbuvir / Ledipasvir	
8 weeks   ☐
* no cirrhosis, treatment naïve, GT1	
12 weeks   ☐	
24 weeks   ☐	
1	
Elbasvir / Grazoprevir	
12 weeks   ☐	 
16 weeks   ☐	
+ Ribavirin    ☐	
1 or 4	
Sofosbuvir plus Daclatasvir	
12 weeks   ☐	
24 weeks   ☐	
+ Ribavirin    ☐	
3 or 1	
Paritaprevir/ritonavir + Ombitasvir + Dasabuvir  	
12 weeks   ☐	1b	
Paritaprevir/ritonavir + Ombitasvir + Dasabuvir + RBV	
12 weeks   ☐	
24 weeks   ☐	
	
1a	
Multiple regimens are available for the treatment of chronic HCV. Factors to consider include HCV genotype, cirrhosis status, prior treatment, viral load, potential drug-drug interactions, comorbidities. 
See  Australian Recommendations for the Management of Hepatitis C Virus Infection: A Consensus Statement 2017 (http://www.gesa.org.au) for all regimens, and for monitoring recommendations. 
Patients must be tested for HCV RNA at least 12 weeks after completing treatment to determine outcome. Please notify the specialist below of the Week 12 post-treatment result.
Declaration by General Practitioner
I declare all of the information provided above is true and correct.	
Signature:		
Name:	<<Doctor:Name>>	
Date:	 <<Miscellaneous:Date>>                 	
Approval by Specialist Experienced in the Treatment of HCV
I agree with the decision to treat this person based on the information provided above. 	
Signature:		
Name:		
Date:	                   	
Once completed, please return both pages by email:                           or fax: