St George Hospital Liver Clinic 
Referrals (fax) : 9113 3993
Phone Enquires: 0409 393 370
Mobile Fibroscan Bookings: 9113 2817
Remote Consultation Request for Initiation of Hepatitis C Treatment
Date: <<Miscellaneous:Date>>
FOR ATTENTION OF: <<FOR ATTENTION OF:>>
GP Name	<<Doctor:Name>>	
GP Suburb /Postcode	<<Doctor:City>> /<<Doctor:Postcode>>	
GP Phone / Fax number	<<Doctor:Phone>> /<<Doctor:Fax>>	
GP Email address	<<Doctor:E-mail>>	
		
Patient Name:	 <<Patient Demographics:Full Name>>	
Patient’s Date of Birth	<<Patient Demographics:DOB>>	
Patient residential Postcode	<<Patient Demographics:Postcode>>	

Hepatitis C History:

Date of HCV Diagnosis  _________

Known cirrhosis*    ☐ Yes       ☐No  

Hepatocellular Ca   ☐ Yes       ☐No
	Intercurrent conditions:

Diabetes             ☐ Yes       ☐No  
Obesity               ☐ Yes       ☐No  
Hepatitis B *        ☐ Yes       ☐No  
HIV *                     ☐ Yes       ☐No  
Alcohol > 40g/d  ☐ Yes       ☐No  
*Surface antigen	

Contraception    ☐ Yes       ☐No  	

Prior antiviral treatment?:
☐ Yes         ☐No        ⃞Unsure
Did the patient previously receive Boceprevir/Telaprevir/Simeprevir?

☐ Yes       ☐No  

Prior Treatment Response:
_____________________________
	Current medications:

I have checked for potential Drug Drug Interactions*  
☐ Yes       ☐No 
 
* http://www.hep-druginteractions.org 	
*Patients with cirrhosis or HBV/HIV coinfection should be referred to a specialist 

   Developed by GESA- Australian Liver Association                                                                                               1 of 
St George Hospital Liver Clinic 
Referrals (fax) : 9113 3993                       
Phone Enquires: 0409 393 370
      Mobile Fibroscan Bookings: 9113 2817

Laboratory Results 	(or attach copy of results) 	
Test	Date	Result	
HCV Genotype			
HCV RNA Level			
ALT			
AST			
Bilirubin			
Albumin			
eGFR			
Haemoglobin			
Platelet Count			
INR			
HBsAg		Positive ⃞  Negative ⃞	
HIV Antibody		Positive ⃞  Negative  ⃞	

   Liver Fibrosis Assessment 	
	Date 	Result*	
Fibroscan			
Other (eg APRI)			
APRI : http://www.hepatitisc.uw.edu/page/clinical-calculators/apri	

*People with Fibroscan score ≥ 12.5 kPa or APRI score ≥ 1.0 should be referred to a specialist 
   Liver Ultrasound	
Date	 Result	

	
Developed by GESA- Australian Liver Association                                                                                                 2 of 3

St George Hospital Liver Clinic 
Referrals (fax) : 9113 3993
Phone Enquires: 0409 393 370
      Mobile Fibroscan Bookings: 9113 2817
Treatment

Treatment advice will returned via fax once specialist approval given.

Patients should be monitored during treatment according to the ‘Australian Recommendations for the Management of HCV Infection’.  

Patients must be tested for HCV RNA at least 12 weeks after completing treatment to determine outcome. A copy of the patient’s final HCV RNA results MUST be emailed to St George Hospital Liver Clinic at the completion of therapy.

Declaration by general practitioner
I declare all of the information to the best of my knowledge provided above is true and correct	
Name:		
Signature:	
	
Date:		

Suggested treatment regime

Regime	Duration	

Specialist approval

I agree with the decision to treat this person based on the information provided above 	
Name:		
Signature:	
	
Date:		

Please follow the link below for the Hepatitis C on-line learning module from the NPS Medicine Wise.  By completing the module and undertaking the assessment, CPD points Cat 2 will be awarded to GPs.
http://learn.nps.org.au/mod/page/view.php?id=7278.
       
 Developed by GESA- Australian Liver Association                                                                  3 of 3