Referral for Breast Symptoms
shc-tr.salisbury-rapidreferralcentre@nhs.net
Patient Details:
Name
Address
<Patient name> (<Gender>)
<Patient address>
Email
<Patient contact details>
Referrer Details:
Referring Clinician
GP Practice
Address
<Sender name>
<Sender details>
<Sender address>
NHS No.
Date of Birth
Home Telephone
Work Telephone
Mobile Telephone
<NHS number>
<Date of birth>
<Patient contact details>
<Patient contact details>
<Patient contact details>
Date of Referral
Dates Not Available
Telephone
Fax
<Todays date>
<Diagnoses>
<Sender details>
<Sender details>
Referral Type:
Referral
Suspected Cancer
Symptomatic Referral
The purpose of differentiation between symptomatic and suspected cancer is to aid the consultation and for tracking purposes.
It does not effect waiting time and all patients will be seen within 2 weeks.
If patient is unable to attend in the next 2 weeks please consider re-referral.
Signs and Symptoms:
Left
Right
<30yrs + Discrete lump
>30yrs + Discrete lump that persist after next period (if premenopausal)
Definite signs of malignancy (ulceration, skin nodules, skin distortion)
Asymmetrical nodularity
Nipple retraction, distortion or eczema
Nipple discharge – unilateral, bloody + spontaneous
Nipple discharge – not unilateral or bloody
Severe mastalgia or persistent unilateral mastalgia in post-menopausal woman
Past history of breast cancer + new signs or symptoms
Breast infection or abscess (contact SAU if emergency admission for IV antibiotics is required)
Suspicious axillary lymphadenopathy
Family history of breast cancer
Other Details:
Has the patient had a mammogram in the last 12 months?
If yes, Date: :
Location:
Yes
No
Additional Information:
<Event Details>
Medical Problems:
<Diagnoses>
Allergies:
<Allergies & Sensitivities>
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Ver 4.0
Medication:
Acutes
<Medication>
Repeats <Repeat templates>
Yours sincerely,
<Sender name>
Sent electronically, no signature required
Email to:
shc-tr.salisbury-rapidreferralcentre@nhs.net
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<Patient name> <NHS number> <Date of birth>