Before completing this form, please check if this patient: Has hepatitis B, HIV, cirrhosis, hepatocellular carcinoma or renal disease, or is pregnant? If yes, do NOT complete this form. These patients should be referred to a specialist via the Central Referral Service or privately. Has chronic hepatitis C, i.e. HCV antibody positive and HCV RNA positive on 2 separate occasions >=6 months apart? If no, patient is not eligible for PBS-funded HCV treatment ATTENTION FOR OF: Dr Date: Infectious disease physician Hepatologist Gastroenterologist Note: GPs and medical practitioners experienced in the treatment of chronic hepatitis C infection are eligible to independently prescribe hepatitis C treatment under the PBS without consulting a gastroenterologist or hepatologist or infectious diseases physician. GP name Dr Practice name Practice address Postcode Phone ( ) Fax ( ) Mobile Email address Date of HCV diagnosis (dd/mm/yyyy): Co-morbidities / / Prior Antiviral Treatment Current Medications (Prescription, herbal, OTC, recreational): Has patient previously received Yes No ☐ ☐ any antiviral treatment? Has prior treatment included oral Yes No antiviral therapy? treatment: I have checked for potential drug–drug interactions with current medications† Yes No ☐ ☐ † If possible, print and fax a PDF from this site showing you have checked drug–drug interactions.
Before completing this form, please check if this patient: Has hepatitis B, HIV, cirrhosis, hepatocellular carcinoma or renal disease, or is pregnant? If yes, do NOT complete this form. These patients should be referred to a specialist via the Central Referral Service or privately. Has chronic hepatitis C, i.e. HCV antibody positive and HCV RNA positive on 2 separate occasions >=6 months apart? If no, patient is not eligible for PBS-funded HCV treatment FOR ATTENTION OF: Dr Date: Infectious disease physician Hepatologist Gastroenterologist Note: GPs and medical practitioners experienced in the treatment of chronic hepatitis C infection are eligible to independently prescribe hepatitis C treatment under the PBS without consulting a gastroenterologist or hepatologist or infectious diseases physician. GP name Dr Practice name Practice address Postcode Phone ( ) Fax ( ) Mobile Email address Date of HCV diagnosis (dd/mm/yyyy): / / Co-morbidities Prior Antiviral Treatment Current Medications (Prescription, herbal, OTC, recreational): I have checked for potential drug–drug interactions with current medications† ☐ Yes ☐ No † If possible, print and fax a PDF from this site showing you have checked drug–drug interactions. Has patient previously received any antiviral treatment? ☐ Yes ☐ No Has prior treatment included oral antiviral therapy? Yes No treatment:
Remote%20consultation%20request%20for%20initiation%20of%20hepatitis%20C%20treatment.docx