GRAMPIANS REMOTE CONSULTATION FOR INITIATION OF HEPATITIS C TREATMENT
Fax to Ballarat Health Services Gastroenterology and Liver Clinic: 03 53204097
Attention: Dr. Al-Ansari
Referral date: <FormattedDate>

GP Details		
Name:	<DrName>	
Provider Number:	<DrProviderNo>	
Practice Address:	<DrAddress>	
Phone no:	<DrPhone>	
Fax no:	<DrFax>	

Patient Details		
Name:	<PtFullName>	
DOB:	<PtDoB>	
Address:	<PtAddress>	

Please refer patients directly to the Ballarat Health Services Gastroenterology and Liver Clinic for specialist assessment if:
•	History, examination or investigations suggestive of cirrhosis (i.e. liver stiffness is > 12.5 kPa or APRI >1.0) or;
•	Previously treated with regimens containing direct acting antiviral agents or;
•	Concomitant medications not listed on the Liverpool website or drug interactions are such that assistance is required or;
•	Patient has received amiodarone in the last 3 months or;
•	Pregnant or breastfeeding female.

Likely year of HCV acquisition:	<Likely year of HCV acquisition>	
Year of chronic hepatitis C diagnosis:	<Year of chronic hepatitis C diagnosis>	

Has the patient ever been diagnosed with cirrhosis?	<Has the patient ever been diagnosed with cirrhosis>	
Is the patient obese (BMI ≥ 30)?	<Is the patient obese (BMI 30+)>	
Is there a history of current or prior alcohol intake >4 std drinks/day?	<Current or prior alcohol intake 4+ std drinks/day>	
Has the patient previously been treated for HCV?	<Previously been treated for HCV>	
If yes, did the treatment contain direct acting antiviral agents?	<If YES, did treatment contain direct acting antiviral agents>	
Are there signs of chronic liver disease on examination?	<Signs of chronic liver disease on examination>	

	Date	Result	
HCV genotype 	<HCV genotype (last 12 months) - DATE>	<HCV genotype - RESULT>	
HCV RNA level	<HCV RNA level - DATE>	<HCV RNA level - RESULT>	
HIV serology	<HIV serology - DATE>	<HIV serology - RESULT>	
HBV sAg	<HBV sAg - DATE>	<HBV sAg - RESULT>	
HBV cAb	<HBV cAb - DATE>	<HBV cAb - RESULT>	
HBV sAb	<HBV sAb - DATE>	<HBV sAb - RESULT>	
Haemoglobin	<Haemoglobin - DATE>	<Haemoglobin - RESULT>	
Platelets	<Platelets - DATE>	<Platelets - RESULT>	
Albumin	<Albumin - DATE>	<Albumin - RESULT>	
AST and AST upper limit of normal	<AST and AST upper limit of normal - DATE>	<AST and AST upper limit of normal - RESULT>	
ALT	<ALT - DATE>	<ALT - RESULT>	
Bilirubin	<Bilirubin - DATE>	<Bilirubin - RESULT>	
eGFR	<eGFR - DATE>	<eGFR - RESULT>	
INR	<INR - DATE>	<INR - RESULT>	
B-HCG if female	<B-HCG if female - DATE>	<B-HCG if female - RESULT>	

APRI	Date:	<APRI - DATE>	Score:	<APRI - Score>	
OR					
FibroScan	Date:	<FibroScan - DATE>	IQR/med(%):	<IQR/med(%)>	
	Median liver stiffness (kPa):	<Median liver stiffness (kPa)>			

<Ix>

The management of this patient will be according to the Australian Recommendations for the Management of HCV infection consensus statement 2017: <The management of this patient will be according to the Australian Recommendations for the Management of HCV infection consensus statement 2017>  

I have used www.hep-druginteractions.org to check and will manage interactions between the patient's current medications (including over the counter and herbal preparations) and:

Sofosbuvir/ledipasvir for genotype 1,2,3,4,5 or 6	<I will manage interactions between patient's current medications andSofosbuvir/ledipasvir for genotype 1,2,3,4,5 or 6>	
Other direct acting antiviral	<I will manage the interactions between the patient's current medications and other direct acting antivirals>	
List of antivirals	<Please list antivirals>	

GP declaration: I declare all of the information provided above is true and correct

GP signature:				Date: <TodaysDate>

Patient Name: <PtSurname>, <PtFirstName> DOB: <PtDoB>
Version October 2017