Referral letter

Dear:				Date:	
Patient Name:					
Address:					
Phone number:			Email:		
DOB:			Medicare Number:	Not eligible?	
HCC/Pension Number:					
Interpreter required? Y  	N  	Language:			
Does the person identify as Aboriginal and/or Torres Strait Islander? Y	N Country of Birth:
Please see as non-urgent review
Please see ASAP. Reason for urgent referral:
The patient is aware of this referral.
I have asked them to call your rooms for an appointment. Please contact the patient to arrange a time.
Reason for Referral
New diagnosis hepatitis B 
Refer to commence treatment
Please assess and advise of management plan for hepatitis B Assume management of hepatitis B
Medical History

Medications (including complementary and Traditional Chinese Medicine)

Allergies

Immunisations
Hepatitis A  Y	N	unsure

Metabolic History
BMI or most recent weight:	OR Obesity Y	N
T2DM
Alcohol/ other drugs: Smoking :

Family history of liver cancer Y	N
Pregnancy or planning Y	N
Upcoming immune suppression / chemotherapy Y	N
Co-infection with HCV or HIV Y	N

Examination: normal	/ other

Previous management of Hepatitis B
Medication Y	N	/please specify N/A (new diagnosis)
Other considerations
Visa and migration considerations to support patient with (further detail in free text)

Investigations
Lab used:

	Attached	Not done	Please organise	
HBsAg, anti-HBc, anti-HBs
Please identify if this has been self-reported by the patient	

	
HBeAg / anti-HBe serology, HBV DNA viral load*
date last done if known	

	
HAV, HCV, HDV, and HIV serology	

	
LFT (inc AST) , FBE, EUC	

	
AFP	

	
INR	

	
Liver ultrasound, imaging (any date), APRI score	

	

For your information I have discussed the following marked topics with Please continue patient education.
Natural history, modes of transmission, and risk reduction
The availability of effective treatments, which are funded by the PBS, if indicated Partner and family immunisation and testing
The need for regular long-term (often lifelong) monitoring - at least annually
Liver health and lifestyle- Alcohol minimisation, smoking cessation, weight management, IDU harm reduction as appropriate Online/ Written Resources
Notes on patient education (including estimated level of patient understanding)

Please:
Develop a plan of management for this patient. I am happy to order tests/ investigations and follow this person up after assessment.
Assume ongoing care and management of HBV. Please keep me informed of your care. Assume care of this patient.

I have prepared a GP Management Plan for this patient. Y	N
Would you be able to join the Team Care Arrangement for this patient? Y	N

Please let me know if you are unable to take on this patient or are unable to contact them.

Regards,

Name Address