REACH-C | Form

REACH-C online form

Please 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 information

Prescriber 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 demographics

Date of birth*

Gender*

Male
Female
Transgender

Aboriginal and/or Torres Strait Islander*

Yes
No
Unknown

Clinical information

Current 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 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.

APRI

HBsAg*

Yes
No
Unknown

HIV infection*

Yes
No
Unknown

HCV genotype

HCV RNA level

< 6 million IU/mL
> 6 million IU/mL
Unknown

HCV therapy

Previous HCV treatment*

No
Yes, interferon-containing
Yes, interferon-free

Planned HCV regimen*

Sofosbuvir/ledipasvir (Harvoni®)
Sofosbuvir/velpatasvir (Epclusa®)
Grazoprevir/elbasvir (Zepatier®)
Glecaprevir/pibrentasvir (Maviret®)
Sofosbuvir/velpatasvir/voxilaprevir (Vosevi®)

Planned duration*

Date of authority prescription:*

If unknown, proposed date

You 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 approval

The following information is required for specialist approval but will not be collected for REACH-C study

Patient Body weight*

if weight is <100kg, add a 0 in front

EtOH current (g/day)*

Please enter a value between 0 and 99.

List of current comorbidities

List of other concurrent medication

Drug-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 comments

SPAM protection

SPECIALIST APPROVAL

Specialist name:

Specialist sign-off:

on

(dd/mm/yyyy)

Result:

Approved
Patient requires specialist referral/assessment
Needs further data

Comments

This field is for validation purposes and should be left unchanged.