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 5202 0555)

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.Gender
Address: Patient Demographics.Full Address
Phone (Home): Patient Demographics.Phone (Home)
Phone (Work): Patient Demographics.Phone (Work)
Phone (Mobile): Patient Demographics.Phone (Mobile)
================================================================================
Referring Doctors Details
Doctor:  Treating Doctor.Name
Provider No: Treating Doctor.Provider Number
Doctor's address: Treating Doctor.Full Address
Phone: Treating Doctor.Phone
Fax: Treating Doctor.Fax
=================================================================================
Previous Hepatitis Treatment
previous tx

===============================================================================
Medical History
Allergies: Clinical Details.Allergies
Active Medical History: Clinical Details.Problem List (Current)
Medication List: Clinical Details.Medications - Current Regular
Natural/Herbal/Supplement: natural/herbal supps

===============================================================================
Investigations

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

Investigations:  Clinical Details.Result List (Selected)

===============================================================================

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		

03d166fbe872bc087092a0000c39da7693e9d82650000000049454e44ae426082  No 
Category assigned:    Cat 1       Cat 2    Cat 3     
Authorising Clinician signature…………………………………….  
Date………………..
Time allocation slots    1     2     3     4

RELEVANT REPORTS AND INVESTIGATIONS:

<Ix>

plain
Re:  Patient Demographics.First Name Patient Demographics.Surname
Address: