Sunshine Coast Hospital & Health Service Central Intake 
HEPATITIS C - MULTI-DISCIPLINARY TEAM REFERRAL FORM

Secure electronic transfer to: (NQ45600007J)
(Alternatively this referral can be faxed to the Central Booking Office on Fax: 07 5470 6377)
DATE OF REFERRAL: <TodaysDate>
Patient Details   
Re: <PtName>
Date of Birth: <PtDoB>  
Age: <PtAge>    
Sex: <PtSex>
Address: <PtAddress>
Phone (Home): <PtPhoneH>
Phone (Work): <PtPhoneWk>
Phone (Mobile): <PtPhoneMob>
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Referring Doctors Details
Doctor: <DrName>
Provider No: <DrProviderNo>
Doctor's address: <DrAddress>
Phone: <DrPhone>
Fax: <DrFax>
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Previous Hepatitis Treatment
<Outline any previous hepatitis treatment>

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Medical History
Allergies: <Reactions>
Active Medical History: <PMHActive> 
Medication List: <CurrentRx>
Natural/Herbal/Supplement: <IMPORTANT: List all natural/herbal/supplements>
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Investigations

NOTE - Essential investigations for referral: 
FBC, E/LFT, INR, Hepatitis B&C serology.  <#1 Essential Ix - FBC, E/LFT, INR, Hep B&C serology>
HCV viral load; HCV Genotype; HIV serology <#2 Essential Ix - HCV viral load, HCV Genotype, HIV serology>
Abdominal USS <#3 Esssential Ix - Abdo USS>
Additional investigations (if available) -  Fibroscan report, liver biopsy report. <Ix if available: Fibroscan report, Liver biopsy report>

Investigations: <Ix>

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HOSPITAL ONLY SECTION: 
DATE OF MDT:  ....................

MDT Decision:

Fibroscan clinic  		Hepatology Clinic  	                 HCC surveillance  

Category assigned:    Cat 1       Cat 2      Cat 3      
Consultant signature…………………………………….  

Investigation Checklist:

ALT		AST		Bili		HbsAg		
GGT		Alb		Hb		HIV		
INR		eGFR		Plats		WCC		
USS		Date						

Genotype		Viral Load		
Fibrosis Stage		Based on		
Fibrosis Assess Value		Date