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.

Please X the corresponding box for the hospital the referral is being made to and fax/send within 24 hours.

Barnet
Fax: 020 8375 1977
Tel: 020 8370 9079 / Chase Farm
Fax: 020 8366 2335
Tel: 020 8370 9079 / BHRUT
Fax: 01708 435 074/ 01708 435 367
Tel: 01708 435 065 / Barts & London
Fax: 020 3465 6622
Tel: 020 3465 5644
Homerton
Fax: 020 8510 7832
Tel: 020 8510 5099 / Newham
Fax: 020 7363 8818
Tel: 020 7363 8817 / North Middlesex
Fax: 020 8887 2663/4
Tel: 020 8887 2662 / Princess Alexandra
Fax: 01279 827 171
Tel: 01279 827 550
Royal Free
Fax: 020 7433 2950
Tel: 020 7443 9757 / UCLH
Fax: 020 3447 9932
Tel: 020 3447 9599 / Whipps Cross
Fax: 020 8928 8836 Tel: 020 8535 6856 / Whittington
Fax: 020 7288 5621
Tel: 020 7288 3070
PATIENT DETAILS (Please complete in block capitals) / GP DETAILS (Please complete in block capitals)
Forename: Surname:
Address:
Post code:
Date of Birth: //
Sex: M F
NHS Number:
Has the patient previously visited the hospital?
Y N
Hospital Number:
Interpreter required: Y N Language: / Name of referrer:
Address:
Post code:
Phone number:
Fax number:
Date referral sent:
IMPORTANT: To be able to contact the patient within 48 hours of referral (day and evening), please provide patients preferred contact phone details / Home:
Daytime:
REFERRAL INFORMATION (Must be completed)
This referral is: Two week wait suspected cancer Symptomatic not suspected cancer
Please tick box & mark diagram
1-5 / a-d
1 / Lump / a / Family history – please attach details
2 / Spontaneous bloody or clear nipple discharge / b / Persistent unilateral nodularity
3 / New nipple alteration / c / Unilateral pain
4 / Skin dimpling / d / Other (please send letter)
5 / Man >50 years unilateral firm mass
R L




Please include relevant clinical information: (complete on separate sheet if necessary)
Please include (Past Medical History/DH/FHx):
Duration of Symptoms:
I confirm that I have discussed the possibility with the patient that the diagnosis may be cancer
I confirm I have performed a full breast examination
I confirm I have included full clinical details either on this form or as a separate attachment
If you wish to discuss any clinical issues relating to this referral please contact:
Barnet Hospital / Tel: 020 8216 4504
Chase Farm Hospital / Tel: 0208 375 1914
Barking, Havering and Redbridge University Hospitals NHS Trust / Cancer Referrals Office:
Tel: 01708 435065
Barts and the London Hospital / Miss Serena Ledwidge; Consultant Breast Surgeon
Tel: 020 3465 5644
Homerton University Hospital NHS Foundation Trust / Miss Laila Parvanta; Consultant Breast Surgeon
Tel: 0208 510 7930
Newham University Hospital / Cancer Pathway Office:
Tel: 020 7363 8817 # 9275/9399
Miss Sally Shanley; Breast CNS
Tel: 020 7363 8357
Mrs G W Constance; Breast CNS
Tel: 020 7363 8357
North Middlesex University Hospital NHS Trust / Mr Fafemi; Consultant Breast Surgeon (via Secretary)
Tel: 0208 887 4047
Princess Alexandra Hospital NHS Trust / Fast Track Office:
Tel: 01279 827550
Royal Free London NHS Foundation Trust / Mr Mo Keshtgar, Mr Deb Ghosh; Consultant Breast Surgeons;
Tel: 020 7830 2794
Mr Tim Davidson
Tel: 020 7830 2794 (Secretary – Jane)
Tina Kelleher; Breast CNS
Tel: 020 7830 2794
University College London NHS Foundation Trust / Miss Jenny Gattuso ; Consultant Breast Surgeon
Tel: 07852 220 200
Whipps Cross University Hospital / Jo McLaughlin
Tel: 0203 465 5620
The Whittington Hospital NHS Trust / Breast CNS – Vivienne Maidens ;
Tel: 020 7288 5147 ext. 3286
Breast co-ordinator – Lotta Johnson
Tel: 020 7288 5947

London Cancer Breast referral form

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