BREAST CLINIC REFERRAL FORM pf3

Breast Unit, St. Margaret’s Hospital, The Plains, Epping, Essex CM16 6TNBreast Clinic Referral FormSurname . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Forename . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DoB . . . . . . . . . .Tel . . . . . . . . . . . . . . . . . . .GP Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Tel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ReferralFast-track (Fax to Breast Unit, SMH: 01992 000000)■ Other (Post to Breast Unit, SMH)■ Family History (Post to Breast Unit, SMH)Symptoms■ Right ■ Left ■ BilateralDuration: . . . . . . . weeks . . . . . . . monthsGP signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Less than 30 years old Other Family History■ New discreet lump ■ Unilateral mastalgia less than 50 years old Number of relatives . . . . . .■ Bloody nipple discharge ■ Persistent/recurrent cyst First degree . . . . . .■ Nipple/skin changes ■ Patient anxiety Second degree . . . . . .Previous breast surgery■ None ■ BBD ■ Cysts ■ CancerMenstrual status Age at 1st pregnancy . . . . . Age of menarche . . . . . .■ Pre-menopausal ■ Peri-menopausal ■ Post-menopausal ■ Not known Parity . . . . . LMP: …/…/…■ Hysterectomy ■ Bilat. Ooph. ■ Unilateral OophNever Past Current Duration (yrs) Age when startedOral contraceptive ■ ■ ■ . . . . . . . . . . . . . . . .HRT ■ ■ ■ . . . . . . . . . . . . . . . .General HealthMedication. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .(Please attach any other relevant supplementary information)Impression■ Benign ■ Indeterminant ■ MalignantFORM CODE/VERSION NO.

REFERRALSPatients suspected by the GP to have breast cancer should be referred by fax on the NLCNsuspected breast cancer proforma (Appendix 1). These cases will be seen within twoweeks. Referrals to the breast clinic not on the appropriate proforma should be screenedby members of the breast surgical team. Any considered suspicious for cancer should alsobe seen within the two week target.REFERRAL TYPES1 Fast Track (