Recommended Referral Criteria & Form

Recommended referral criteria

Any woman 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 breast cancer diagnosis AND one of the following meet criteria for genetic testing:

Jewish Ancestry
Diagnosed < age 45
Bilateral breast cancer < age 60
Triple negative tumour
Ovarian cancer
Male breast cancer
Parent/child or sibling meeting 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):

Client's Details

Client's titles*

Client's first name *

Client's last name *

Client's email *

Client's postcode *

Client's address 1*

Client's address 2

Client's city *

Client's date of birth

Client'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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