Orange Liver Clinic
Dr Geoffrey Chu  M.B.B.S,F.R.A.C.P
Kite St Community Centre
96 Kite Street, Orange NSW 2800
Ph: 6393 4800           Fax: 6393 4852		
REFERRAL FOR LIVER CONSULTATION
Complicated Liver Disease / Cirrhosis Only
Name:	    <PtName>	D.O.B:	   <PtDoB>	Sex:  <PtSex>	
Address:	   <PtAddress>	
Telephone:	(H)   <PtPhoneH>	(W)   <PtPhoneWk> (M)  <PtPhoneMob>	
Medicare	   <PtMCNo>	Private Fund: <PtHealthIns>        	
Email Address:	<PtEmail>	Lives Alone: <Does patient lives alone?>	
DVA Gold Card holder:	   <PtDVANo>	Aboriginal or Torres Strait Islander:	   <PtEthnicity>	

PLEASE NOTE: This is specifically for a liver Clinic for patients with cirrhosis or complex liver disease 
Description of problems:
<Description of problems>

	
Please have the following investigations done & include the results with the referral.
Pathology - (Copy & Paste results for below)
FBC, INR, LFT's, EUC, Random glucose, POA CA

For cirrhosis/co-infection viral hepatitis include HCV PCR Quantitative & Genotype, Hep A AB, HBVBsAB, HBVBsAg, HIV, AFP	
Radiology: (Copy & Paste results) - Abdominal ultrasound for suspected cirrhosis 
	
Referring Doctors Details 
Doctors Name: <DrName>			Doctors Provider Number: <DrProviderNo>
Practice Name: <Practice>
Practice Address: <UsrAddress>                Practice Phone: <UsrPhone>

Doctors Signature:  					                   Date:  <TodaysDate>

THIS IS NOT A GASTROENTEROLOGY CLINIC