GP REFERRAL PROFORMA FOR ALL BREAST SYMPTOMS
PLEASE USE 2WW SERVICE ON CHOOSE AND BOOK OR FAX TO 01823 343 417 (MPH) OR 01935 384 640 (YDH)
Decision to refer date (to be completed by GP):
Do you suspect that this patient may have cancer?
Referral received date (to be completed by hospital):
Yes
No (Must be completed)
Please note: All breast referrals are now mandated to be seen within 14 days of receipt of referral and thus patients should be
made aware they will receive an appointment within this timescale. Ticking the above box indicates an increased suspicion of
cancer and should be completed for those patients who you consider may have a breast cancer, this is important as these
patients will be tracked against the National Cancer Waiting Times Target.
If yes: Has the patient been informed that they are being referred for suspected cancer?
Has the patient been given the 2WW referral patient information leaflet?
Dates patient is unavailable in next 14 days:
Patient Details:
Referring GP Details:
Surname:
NHS No:
Name:
Forename:
Hosp No:
Address:
Practice:
Post Code:
DOB:
Yes
Yes
No
No
Telephone No:
Fax No:
E-mail Address:
Daytime Tel No:
Mobile Tel No:
Mammogram in last 3 years? Yes / No
Location?
Date?
Re-Referral? Yes / No
Date Last Referred
Family history of breast cancer?
If Yes, please specify:
Yes
No
SYMPTOMS
(please tick all that apply):
Any age with a lump
Any age with breast pain
Any age, with previous breast cancer, who present with a
further lump or suspicious symptoms
Unilateral eczematous skin or nipple
Nipple distortion
Spontaneous nipple discharge
Males with a firm subareolar area mass
Abscess
Recurrent cyst
If you wish to refer for any of the following: family history surveillance, reconstruction, or High Risk Breast Cancer Surveillance (e.g.
previous high risk lesions such as LCIS, ADH, previous mantle radiotherapy or family history / mutation carriers)
Please tick here only
and refer direct to the following locations: Breast Care Centre for MPH referrals or Fax to 01935 384 640 for
YDH referrals
Please attach* additional clinical details to include:
 significant medical history and co-morbidities
 current medication clearly indicating if the patient is receiving any anti coagulation therapy.
 recent blood results and any other relevant information
* Please note that referrals received without adequate supporting clinical information cannot be processed
and will be returned to the referrer as incomplete
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