Primary Care Consultation Request 
Initiation of Hepatitis C Treatment in Victoria 	
Alfred Hospital Liver Clinic (Gastroenterology)	Fax: (03) 9076 2194	
Alfred Hospital Infectious Diseases	Fax: (03) 9076 6528	
Austin Health Liver	Fax: (03) 9496 2097	
Box Hill Hospital Liver and Hepatitis Clinics	Fax: (03) 9895 4852	
St Vincent's Hospital Melbourne Liver & Hepatitis Clinic	Fax: (03) 9231 3596	
The Royal Melbourne Hospital Liver Clinic	Fax: (03) 9342 7848	
Victorian Infectious Diseases Service – Infectious Hepatitis Clinic	Fax: (03) 9342 7277	
Western Health Hepatitis Clinic	Fax: (03) 8345 7217	

Note: All fields below are mandatory	
ATTENTION OF Dr (if known): 	
GP DETAILS	
Name: <DrName>	Provider No: <DrProviderNo>	
Address: <DrAddress>	
Phone: <DrPhone>	Fax: <DrFax>	Email: <DrEmail>	
PATIENT DETAILS 	
Name: <PtName>	UR No (if known): 	
Date of Birth: <PtDoB>	Gender: <PtSex>	
Pregnant or nursing female*: <Pregnant/Nursing Female>		
FibroScan Date: <Date of Last FibrosScan>	Median Liver Stiffness (kPa): 	<Median Liver Stiffness (kPa) >
Is it >12.5?* 	<Median Liver Stiffness above >12.5 >
IQR/med (%): 	<IQR/med (%)>	
Date: <Date APRI Score Recieved>
	APRI Score: 	<APRI Score >      
Is it >1.0?* 	<APRI Score >1.0>	
* If ANY apply, please refer to a specialist for clinical review 
Hepatitis C History	Intercurrent Conditions 	
Likely year of acquisition: <Likely year of acquisition>	Diabetes: <Diabetes >	
Year of chronic C Diagnosis: <Year of Chronic hep C diagnosis?>	Obesity (BMI>30): <BMI >30 >	
Known Cirrhosis*: <Known Cirrhosis?>	Immunosuppressed:<Immunosuppressed >	
Hepatic Decompensation (ascites, encephalopathy, variceal bleeding)* <Sign of Decompensation>	Hepatitis B*: <Hepatitis B>	
Any previous treatment with Direct Acting Antivirals for HCV: <previous treatment with direct acting antiviral? >	HIV*: <HIV >	
* If ANY apply, please refer to a specialist for clinical review	Alcohol>40g/day:<Alcohol >40g/day>	
LABS (OR ATTACH COPY OF RESULTS 	
Test	Result	Date	Test	Result	Date 	
HCV Genotype:	<HCV Genotype Test Result >	<HCV Genotype Test Date>	INR:	<INR Test Result>	<INR Test Date>	
Viral Load:	<Viral Load Test Result>	<Viral Load Test Date>	Creatinine:	<Creatinine Test Result>	<Creatinine Test Date>	
ALT:	<ALT Test Result>	<ALT Result Date>	eGFR:	<eGFR Test Result>	<eGFR Result Date>	
AST:	<AST Test Result>	<AST Test Date>	Hb:	<Hb Test Result>	<Hb Result Date>	
Total Bilibrubin:	<Total Bilibrubin Test Result>	<Bilibrubuin Test Date>	Platelets:	<Platelets Test Result>	<Platelets Test Date>	
Albumin:	<Alumin Test Result >	<Albumin Test Date>	β HCG:	<ß HCG Test Result>	<ß HCG Result Date>	

DRUG INTERACTIONS AND COUNSELLING	
I have entered current medication (prescription and over-the-counter) and proposed treatment regimen according to genotype into http://www.hep-druginteractions.org/ and assessed outputs. 
Recommend printing and attaching the outputs.
NB: Current GP practice software is NOT sufficient for assessing these potential drug interactions. Complementary and alternative medicines should already be ceased and therefore not entered. 	Yes o 	No o 
On no Medication o 	
Amiodarone at any time in last 3 months:	Yes o 	No o 	
*If hep-drug interactions chart RED or AMBER please await specialist response	
Cease ALL non-traditional (complementary and alternative) medicines during treatment:	Yes o 	No o 	N/A o  	
Contraception education given (males and females):	Yes o 	No o 	N/A o  	
Management of this patient will be according to Australian Recommendations for the Management of HCV infection consensus statement 2017. 	Yes o 	No o 	
HCV INTENDED TREATMENT REGIMEN (for patients with NO CIRRHOSIS)	
Regimen	Genotype	Duration	Please tick 	
Sofosbuvir + ledipasvir	1	8 weeks	 o 	
	1	12 weeks	 o 	
Sofosbuvir + daclatasvir	1	12 weeks	 o 	
	3	12 weeks	 o 	
Sofosbuvir + ribavirin	2 	12 weeks	 o 	
Paritaprevir + ritonavir + ombitasvir + dasabuvir	1b	12 weeks	 o 	
Paritaprevir + ritonavir + ombitasvir + dasabuvir + ribavirin	1a	12 weeks 	 o 	
Grazoprevir + elbasvir	1	12 weeks	 o 	
	4	12 weeks	 o 	
Sofosbuvir + velpatasvir	1,2,3,4,5,6	12 weeks 	               o	

Monitoring of patients on treatment see- Australian Consensus Statement, HealthPathways or Hepatitis Victoria
Alcohol and other drugs (AOD) support see - DirectLine, VIctorian AOD intake and assessments numbers and DHHS. 

DECLARATION OF PRIMARY HEALTH CARE PROVIDER: 

I declare all of the above information provided is complete, true and correct. 
Name:	Date:	
Signature:

DECLARATION OF HCV SPECIALIST: 
I agree / do not agree with the decision to treat this person based on the information provided above. 
Name:	Date:	
Signature: 
	
Additional comments (e.g. incomplete information provided/requires referral to clinic):