REACH-C REACH-C online form Please complete the form below, including patient and doctor details. This information will be reviewed by a specialist, and you will receive an email to provide the approval to treat. All patient data is de-identified and will have a client ID code automatically generated for identification purposes. Please note: Reach-C is no longer a research project being undertaken by The Kirby Institute. * Indicates required fieldDate of request* DD slash MM slash YYYY Prescriber informationPrescriber name*Prescriber phone number (mobile)*Prescriber phone number (surgery)Prescriber email address* Please use personal work email if available (not general reception email).Prescriber type* General practitioner Nurse practitioner Prescriber postcode*Patient demographicsDate of birth* DD slash MM slash YYYY Gender* Male Female Transgender Aboriginal and/or Torres Strait Islander* Yes No Unknown Clinical informationCurrent opioid substitution therapy:* Yes No Unknown Injecting drug use (any in last 6 months)* Yes No Unknown Cirrhosis:* Yes No Unknown FibroScan score (if available)AST (U/L)Please enter a number greater than or equal to 0.Upper limit of normal (AST)Please enter a number from 0 to 99.ALT (U/L):Please enter a number greater than or equal to 0.Platelets (10^9/L)Please enter a number greater than or equal to 0.eGFR (mL/minBSAc):Please enter a number greater than or equal to 0.APRIHBsAg* Yes No Unknown HIV infection* Yes No Unknown HCV genotype 1a 1b 2 3 4 5 6 HCV RNA level < 6 million IU/mL > 6 million IU/mL Unknown HCV therapyPrevious HCV treatment* No Yes, interferon-containing Yes, interferon-free Planned HCV regimen* Sofosbuvir/velpatasvir (Epclusa®) Glecaprevir/pibrentasvir (Maviret®) Sofosbuvir/velpatasvir/voxilaprevir (Vosevi®) Planned duration* 8 weeks 12 weeks 16 weeks 24 weeks Date of authority prescription:* DD slash MM slash YYYY If unknown, proposed dateInformation required for specialist approvalPatient Body weight*if weight is <100kg, add a 0 in frontEtOH current (g/day)*Please enter a number from 0 to 99.List of current comorbiditiesList of other concurrent medicationDrug-drug interactions reviewed*Please check result from HEP Drug Interaction Checker at http://www.hep-druginteractions.org/ Yes No Assessed for adherence*E.g. note any change in medication, dose reduction required Yes No Notes:Additional commentsSPAM protectionThis field is hidden when viewing the formSPECIALIST APPROVALThis field is hidden when viewing the formSpecialist name:This field is hidden when viewing the formSpecialist sign-off:This field is hidden when viewing the formon DD slash MM slash YYYY (dd/mm/yyyy)This field is hidden when viewing the formResult: Approved Patient requires specialist referral/assessment Needs further data This field is hidden when viewing the formClient IDPatient Consent* Please acknowledge by ticking this box that you have informed your patient that their deidentified information is being provided through the Reach-C service for the treatment guidance from a Infectious Disease Physician.PhoneThis field is for validation purposes and should be left unchanged.
