«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth»
NHS no: «PATIENT_Current_NHS_Number» «PRACTICE_Name»
BREAST CLINIC REFERRAL FORM
Press the <Ctrl> key while you click on this link to VIEW REFERRAL GUIDELINES
REFERRAL DATE: «SYSTEM_Date»
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 on this link 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
Barnet
Barts & London
BHRUT
Chase Farm
Homerton
Newham
North Middlesex
Princess Alexandra
Royal Free
UCLH
Whipps Cross
Whittington
Phone
Fax
Email: select & copy to email client
020 8370 9079
020 8375 1977
RF-tr.bcf2weekwaitreferrals@nhs.net
020 3465 5644
020 3465 6622
01708 435 065
01708 435 074/367
020 8370 9079
020 8375 1977
020 8510 5099
0020 8510 7832
020 7363 8817
020 7363 8818
020 8887 2661/2662/3390
020 8887 2663
Northmid.2weekwaitteam@NHS.net
01279 827 550
01279 827 171
tpa-tr.FastTrackReferrals@nhs.net
020 7433 2973/4
020 7433 2950/1
020 3447 9599
020 3447 9932
0208 539 5522 extensions
4348/4349/4350
020 7288 3736/3542
RF-tr.bcf2weekwaitreferrals@nhs.net
uclh.2ww@nhs.net
0208 928 8836
020 7288 5621
twowwbookings.whitthealth@nhs.net
Patient has previously visited selected hospital
HOSPITAL No:
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
SURNAME: «PATIENT_Surname» FIRST NAME: «PATIENT_Forename1» TITLE: «PATIENT_Title»
GENDER: «PATIENT_Sex» DOB: «PATIENT_Date_of_Birth»
NHS NO: «PATIENT_Current_NHS_Number»
ETHNICITY:
LANGUAGE:
INTERPRETER REQUIRED
TRANSPORT REQUIRED
PATIENT ADDRESS: «PATIENT_House» «PATIENT_Road», «PATIENT_Locality», «PATIENT_Town»,
«PATIENT_County», «PATIENT_Postcode»
DAYTIME CONTACT:
HOME: «PATIENT_Main_Comm_No» MOBILE: «PATIENT_Mobile_No»
WORK: «PATIENT_Alt_Comm_No»
EMAIL:
Breast Clinic Referral Form
(Version: V1.1; 17/06/2015)
Page 1 of 3
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth»
NHS no: «PATIENT_Current_NHS_Number» «PRACTICE_Name»
GP DETAILS
USUAL GP NAME: «PATIENT_Usual_GP»
PRACTICE NAME: «PRACTICE_Name» PRACTICE CODE:
PRACTICE ADDRESS: «PRACTICE_House» «PRACTICE_Road», «PRACTICE_Locality»,
«PRACTICE_Town», «PRACTICE_County», «PRACTICE_Postcode»
BYPASS:
MAIN: «PRACTICE_Main_Comm_No» FAX: «PRACTICE_Fax_No»
REFERRING CLINICIAN: «REFERRAL_Clinician»
EMAIL:
CLINICAL DETAILS
Please tick boxes below. Then mark the breast diagram and/or provide 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.
Clinical Description including site, size, consistency and axillary involvement:
Duration of symptoms:
Family history of cancer including age at diagnosis:
Breast Clinic Referral Form
(Version: V1.1; 17/06/2015)
Page 2 of 3
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB: «PATIENT_Date_of_Birth»
NHS no: «PATIENT_Current_NHS_Number» «PRACTICE_Name»
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 that 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 on this link to view the leaflet
Please include the results of any relevant available investigations with this form.
PAST MEDICAL HISTORY
«MEDICAL_HISTORY»
PROBLEMS
«PROBLEMS»
ALLERGIES
«DRUG_ALLERGY»
MEDICATION
«REPEATS»
Breast Clinic Referral Form
(Version: V1.1; 17/06/2015)
Standard NHS Referral Form Layout & Artwork created by Dr Ian Rubenstein
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