Sunshine Coast Hospital & Health Service (SCHHS) Central Intake 
HEPATITIS C - MULTIDISCIPLINARY TEAM REFERRAL FORM

Secure electronic transfer to: (NQ45600007J)
(Alternatively this referral can be faxed to the Central Booking Office on Fax: 07 5202 0555)

Note the above fax number is for the OUTPATIENT DEPT only and cannot be used for Emergency Department, please refer to the SCHHS pathways link below for further information
HealthPathways (HP) Sunshine Coast and Gympie

Date of Referral: <TodaysDate>

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Patient Details   
Re: <PtFullName>
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>
Practice Name:<Practice>
Practice Address: <UsrAddress>
Practice Phone: <UsrPhone>
Phone Fax: <UsrFax>
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Previous hepatitis treatment:  <Outline any previous viral hepatitis treatment:>
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Current and Past Clinical History
Allergies/ Adverse Events: <Reactions>
Medication List: <CurrentRx>
Active Medical and Surgical History:  <PMHActive>
Natural/Herbal/Supplements: <IMPORTANT - List all natural/herbal/supplement medications>
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Investigations

NOTE- Essential investigations for referral:
FBC, E/LFT, INR, Hepatitis B&C serology - <#1 Essenital Ix - FBC, E/LFT, INR, HepB&C serology>. 
HCV viral load; HCV Genotype; HIV serology - <#2 Essential Ix - HCV viral load, HCV genotype, HIV serology> 
Abdominal USS - <#3 Essential Ix - Abdominal USS> 

Additional investigations (if available) -  Fibroscan report, liver biopsy report -  <Additional Ix (if available) - Fibroscan report, liver biopsy report> 
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Investigations: <Ix>  

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