Referral Form	

Referring DR Name: <DrName>
Practice: <Practice>
Address: <UsrAddress>										
Phone:	<UsrPhone>		Fax: <UsrFax>			
Email: <PracEmail>

Patient Details	

First Name(s):	<PtFirstName>		Family Name: <PtSurname>
Preferred Name: <PtPrefName>
Date of Birth: <PtDoB>
Address: <PtAddress>
Contact Number: <PtPhoneMob>
___________________________________________________________________________
Support Worker / Carer details: <Carer Name (if applicable)>
Contact Number: <Carer Phone (if applicable)>
Is an interpreter required?  <Interpreter Required? Yes/ No>

Clinical Information	

Past Medical History: <PMHActive>
Current Medications: <CurrentRx>
Allergies: <Reactions>

Relevant Investigations and Tests	

  Hep C Ab 	    		Hep C Viral Load					               

  LFT inc AST		            FBC				

  Hepatitis A + B serology - HbsAg, anti HBc, anti HBs

Other Helpful Investigations:    
			
  INR	   	             U + E		   HIV / Syphilis

  Upper Abdominal Ultrasound with Shearwave Elastography