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: <<Doctor:Name>>	Provider No: <<Doctor:Provider Number>>	
Address: <<Doctor:Full Address>>	
Phone: <<Doctor:Phone>>	Fax: <<Doctor:Fax>>	Email: <<Doctor:E-mail>>	
PATIENT DETAILS 	
Name: <<Patient Demographics:Full Name>>	UR No (if known): 	
Date of Birth: <<Patient Demographics:DOB>>	Gender: <<Patient Demographics:Sex>>	
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:	<<B HCG Test Result>>	<<B 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) supporrt - see DirectLine, Victorian AOD intake and assessment numbers and DHHS. 

DECLARTION OF PRIMARY HEALTH CARE PROVIDER: 
Name:	Date:	
Signature: 

DECLARATION OF HCV SPECIALIST: 
Name:	Date:	
Signature:
	
Additional Comments (e.g. incomplete infromation provided/ requires referral to clinic):