Breast Clinic & 2 Week Referral Form
DOB: NHSno:
Breast Clinic Referral Form
Press the <Ctrl> key while you click hereto VIEW REFERRAL GUIDELINES
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
DOB: NHSno:
REFERRALDATE:
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
DOB: NHSno:
For all breast referrals-not only 2ww cancer referrals
For Choose and Book referrals, attach this template to a referral in Choose and Book within 24 hours of creating the request - an appointment must be made for the patient before they leave the practice.
Press the <Ctrl> key while you click here to VIEW LEAD CLINICIAN CONTACT INFORMATION
Please X the corresponding box for the hospital the referral is being made to and fax/send within 24 hours.
Hospital / Phone / Fax / Email: use <Ctrl> key + click on linkBarnet / 020 8370 9079 / 020 8375 1977 /
Chase Farm / 020 8370 9079 / 020 8375 1977 /
BHRUT / 01708 435 065 / 01708 435 074/367
Barts & London / 020 3465 5644 / 020 3465 6622
Homerton / 020 8510 5099 / 0020 8510 7832 /
Newham / 020 7363 8817 / 020 7363 8818
North Middlesex / 020 8887 2661/2662/3390 / 020 8887 2663 /
Princess Alexandra / 01279 827 550 / 01279 827 171 /
Royal Free / 020 7433 2973/4 / 020 7433 2950/1
UCLH / 020 3447 9599 / 020 3447 9932 /
Whipps Cross / 020 8535 6856 / 020 8928 8836
Whittington / 020 7288 3736/3542 / 020 7288 5621 /
Patient has previously visited selected hospital HOSPITALNo:
PLEASE INDICATE THE NATURE OF THIS REFERRAL BELOW:Two week wait - suspected cancer
Symptomatic - not suspected cancer
Referral to Family History Clinic
Other (please specify):
PATIENT DETAILS
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
DOB: NHSno:
SURNAME: FIRSTNAME: TITLE:
GENDER: DOB: NHSNO:
ETHNICITY: LANGUAGE:
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
DOB: NHSno:
INTERPRETER REQUIRED TRANSPORT REQUIRED
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
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PATIENTADDRESS: POSTCODE:
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
DOB: NHSno:
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
DOB: NHSno:
DAYTIMECONTACT:
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
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HOME: MOBILE: WORK:
EMAIL:
OPTIONAL DETAILS
ACCESS DETAILS: (e.g. Keypad number, someone to phone, neighbour)
CARER DETAILS: (Title + Name + Relationship)
NEXT OF KIN DETAILS: (Title + Name + Relationship)
GP DETAILS
USUALGPNAME:
PRACTICENAME:
PRACTICEADDRESS:
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
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BYPASS:
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
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MAIN: FAX: EMAIL:
REFERRING SERVICE DETAILS
REFERRINGSERVICENAME:
REFERRINGSERVICEADDRESS:
REFERRING SERVICE CONTACT DETAILS
MAIN: FAX: EMAIL:
THIS REFERRAL IS FROM
GP Referring Service
REFERRINGCLINICIAN:
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
DOB: NHSno:
CLINICAL DETAILS
Please tick boxes below. Then mark the breast diagram and/orprovide a clinical description below it.1-5 / a-d
1 / Lump / a / Family history – see below
2 / Spontaneous bloody or clear nipple discharge / b / Persistent unilateral nodularity
3 / New nipple alteration / c / Unilateral pain
4 / Skin dimpling / d / Other (see clinical description)
5 / Man >50 years unilateral firm mass
HOW TO MARK THE DIAGRAM
Place the mouse cursor over the diagram at the position of the lesion. Click the left mouse button. Use the keyboard to mark the diagram (X marks the lesion). Use the mouse or arrow keys to move left or right or to adjacent lines. Please do not press the <ENTER> key as it may cause alignment problems with your markers.
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
DOB: NHSno:
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
DOB: NHSno:
Clinical Description including site, size, consistency and axillary involvement:
Duration of symptoms:
Family history of cancer including age at diagnosis:
I confirm that I have discussed the possibility with the patient that the diagnosis may be cancerI confirm that I have explained the two week wait appointment process to the patient
I confirm I have performed a full breast examination
Reason if breast examination not performed:
Please hand the patient a copy of the URGENT REFERRALS PATIENT INFORMATION LEAFLET
Press the <Ctrl> key while you click here to view the leaflet
CLINICALLY-SPECIFIC AUTOMATIC TABULATED DATA
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
DOB: NHSno:
ROUTINE AUTOMATIC TABULATED DATA
PAST MEDICAL HISTORY
ALLERGIES
MEDICATION
CLINICALLY-SPECIFIC AUTOMATIC TABULATED DATA
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein
DOB: NHSno:
ROUTINE AUTOMATIC TABULATED DATA
Breast Clinic Referral FormPage 1 of 3
(Version: Test 12; Released: 15/12/2014)
Layout & artwork created by Dr Ian Rubenstein