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: Treating Doctor.Name	Provider No: Treating Doctor.Provider Number	
Address: Treating Doctor.Full Address	
Phone: Treating Doctor.Phone	Fax: Treating Doctor.Fax	Email:Treating Doctor.E-mail	
PATIENT DETAILS 	
Name: Patient Demographics.Full Name	UR No (if known): UR 	
Date of Birth: Patient Demographics.DOB	Gender: Patient Demographics.Gender	
Pregnant or nursing female*: Pregnant/Nursing		
FibroScan Date: FibroScan

	Median Liver Stiffness (kPa): kPa
Is it >12.5?*  kPa >	
APRI Score: APRI http://www.hepatitisc.uw.edu/page/clinical-calculators/apri
Date: Date of last APRI	IQR/med (%):IQR/med
Result: IQR/med 
Is it >1.0?*: IQR/Med Result	
* If ANY apply, please refer to a specialist for clinical review 	
Hepatitis C History	Intercurrent Conditions 	
Likely year of acquisition:Acquisition	Diabetes: Diabetes	
Year of chronic hepatitis C Diagnosis: Chronic Hep C	Obesity (BMI>30): BMI	
Known Cirrhosis*: Cirrhosis	Immunosuppressed: Immuno	
Hepatic decompensation (ascites, encephalopathy, variceal bleeding)*: Hepatic Decomp	Hepatitis B*: Hep B	
Any previous treatment with Direct Acting Antivirals for HCV: Direct Antivirals	HIV*: HIV	
* If ANY apply, please refer to a specialist for clinical review	Alcohol >40g/day: Alcohol 	
LABS (OR ATTACH COPY OF RESULTS)	
Test	Result	Date	Test	Result	Date 	
HCV Genotype:	HCV Genotype	HCV	INR:	INR	INR	
Viral Load:	Viral Load	Viral 	Creatinine:	Creatinine	Creatinine	
ALT:	ALT	ALT	eGFR:	eGFR	eGFR	
AST:	AST 	AST 	Hb:	Hb Result 	Hb Result 	
Total Bilibrubin:	Total Bilbrubin	Bilbrubin	Platelets:	Platelets 	Platelets 	
Albumin:	Albumin	Albumin	ß HCG:	B  HCG	B  HCG	

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, Victoria 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):