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)

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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 link
Barnet / 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

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DOB: NHSno:

SURNAME: FIRSTNAME: TITLE:

GENDER: DOB: NHSNO:

ETHNICITY: LANGUAGE:

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DOB: NHSno:

INTERPRETER REQUIRED TRANSPORT REQUIRED

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DOB: NHSno:

PATIENTADDRESS: POSTCODE:

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DAYTIMECONTACT:

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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:

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DOB: NHSno:

BYPASS:

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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

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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 cancer
I 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

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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