REACH-C REACH-C online formPlease fill out patient and doctor details below to have data reviewed by a specialist. Patient data is de-identified and collected for the REACH-C Study. We will contact you via email to provide the approval to treat. We will also contact via email when your patient has reached SVR12 (HCV RNA testing 12-weeks post-treatment) to confirm that they are cured. * Indicates required field Date of request* Patient Initials*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 practitionerNurse practitionerPrescriber postcode*Patient demographicsDate of birth* Gender*MaleFemaleTransgenderAboriginal and/or Torres Strait Islander*YesNoUnknownClinical informationCurrent opioid substitution therapy:*YesNoUnknownInjecting drug use (any in last 6 months)*YesNoUnknownCirrhosis:*YesNoUnknownFibroScan score (if available)AST (U/L)Please enter a value greater than or equal to 0.Upper limit of normal (AST)Please enter a value between 0 and 99.ALT (U/L):Please enter a value greater than or equal to 0.Platelets (10^9/L)Please enter a value greater than or equal to 0.eGFR (mL/minBSAc):Please enter a value greater than or equal to 0.APRIHBsAg*YesNoUnknownHIV infection*YesNoUnknownHCV genotype1a1b23456HCV RNA level< 6 million IU/mL> 6 million IU/mLUnknownHCV therapyPrevious HCV treatment*NoYes, interferon-containingYes, interferon-freePlanned HCV regimen*Sofosbuvir/ledipasvir (Harvoni®)Sofosbuvir/velpatasvir (Epclusa®)Grazoprevir/elbasvir (Zepatier®)Glecaprevir/pibrentasvir (Maviret®)Sofosbuvir/velpatasvir/voxilaprevir (Vosevi®)Planned duration*8 weeks12 weeks16 weeks24 weeksDate of authority prescription:* If unknown, proposed dateYou will be contacted by the REACH-C study team to collect the 12 week post-treatment outcome and adherence for this patient.Information required for specialist approvalThe following information is required for specialist approval but will not be collected for REACH-C studyPatient Body weight*if weight is <100kg, add a 0 in frontEtOH current (g/day)*Please enter a value between 0 and 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/YesNoAssessed for adherence*E.g. note any change in medication, dose reduction requiredYesNoNotes:Additional commentsSPAM protectionSPECIALIST APPROVALSpecialist name:Specialist sign-off:on (dd/mm/yyyy)Result:ApprovedPatient requires specialist referral/assessmentNeeds further dataCommentsThis field is for validation purposes and should be left unchanged.