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Recommended Referral Criteria & Form

Recommended referral criteria

Any women concerned about her family history should be referred for a comprehensive risk assessment, and screening recommendations; particularly those diagnosed under the age of 40

Clients with a personal history of breast cancer AND one of the following meet criteria for genetic testing:

Jewish Ancestry
Diagnosed < 40 years
Diagnosed < 60 years AND triple negative
Ovarian cancer diagnosis
Bilateral breast cancer
Male breast cancer
Significant family history:

- 2+ relatives diagnosed with breast cancer

- Relative with ovarian cancer

- Relative with male breast cancer

Unaffected women with a FDR meeting the above criteria

If your patient has Private Medical Insurance please click here to assess if your patient is likely to be covered.

Referral to (if known):

Clients's Details

Clients's titles*

Clients's first name *

Clients's last name *

Clients's email *

Clients's postcode *

Clients's address 1*

Clients's address 2

Clients's city *

Clients's date of birth

Clients's telephone *

Routine/Urgent

Reason for referral *

Consultant Details

Your name + title

Your telephone

Your email

Hospital/Clinic

Message/Question:

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Genetic Counselling Services
If you have a family history of cancer

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