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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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* Mandatory field
Genetic Counselling Services
If you have a family history of cancer
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