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: <<Miscellaneous:Date>>
Patient Details   
Re:<<Patient Demographics:Full Name>>
Date of Birth:<<Patient Demographics:DOB>>  
Age: <<Patient Demographics:Age>>    
Sex: <<Patient Demographics:Sex>>
Address: <<Patient Demographics:Address>>
Phone (Home): <<Patient Demographics:Phone (Home)>>
Phone (Work): <<Patient Demographics:Phone (Work)>>
Phone (Mobile): <<Patient Demographics:Phone (Mobile)>>
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Referring Doctors Details
Doctor:  <<Doctor:Name>>
Provider No: <<Doctor:Provider Number>>
Doctor's address: <<Doctor:Address>>
Phone: <<Doctor:Phone>>
Fax: <<Doctor:Fax>>
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Previous Hepatitis Treatment
<<Outline any previous Hepatitis treatment>>

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Medical History
Allergies: <<Clinical Details:Allergies>>
Active Medical History: <<Clinical Details:History List>> 
Medication List: <<Clinical Details:Medication List>>
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, HepB&C serolog>>
HCV viral load; HCV Genotype; HIV serology  <<#2 Essential Ix- HCV viral load; HCV Genotype, HIV>>
Abdominal USS  <<#3 Essential Ix- Abdo USS>>
Additional investigations (if available) -  Fibroscan report, liver biopsy report. <<Ix if available- Fibroscan report, Liver biopsy report>>

Investigations:  <<Summary:Investigation Results (Selected)>>

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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