Secure electronic transfer to: Breast Health Centre (0056000B)

PATIENT DETAILS:	
Re:  Patient Demographics.Full Name             Date of birth:  Patient Demographics.DOB
Address:  Patient Demographics.Full Address
Daytime phone: Patient Demographics.Phone (Home)    Mobile: Patient Demographics.Phone (Mobile)	

REFERRAL TYPE: (Please select required procedure/s)		
SCREENING- Yes/ No    SCREENING   Medicare rebate may not be applicable  

Screening Assessment  includes
- 3D Tomosynthesis Mammogram and Breast Nurse clinical examination

If indicated may include:
- Breast Ultrasound
   
- Imaging-guided Biopsy (including FNA,ultrasound guided     core biopsy or stereotatic guided biopsy) 

	DIAGNOSTIC ASSESSMEN - DIAGNOSTIC ASSESSMENT
  
  Diagnostic Assessment includes:  
- Breast Physician consultation 

- Tomosynthesis Mammogram and/or Breast Ultrasound

- Imaging-guided Biopsy-if indicated  (including FNA, ultrasound guided core biopsy or sterotactic guided biopsy)

  Localisation:  Localisation 

 Films required prior to allocation of appointment.	

CLINICAL DETAILS (Please provide written detail)
CLINICAL DETAILS (pl
Lump:  Lump details                    
Thickening:  Thickening details
Dimple:   Dimple details                   
Pain:   Pain details
Inflammation:   Inflammation details                
Discharge:  Discharge details

REFERRING DOCTOR:	
Name: Treating Doctor.Name                                      Provider No. Treating Doctor.Provider Number
Practice name: Practice.Name
Practice address: Practice.Address
Telephone: Practice.Phone                                         Fax: Practice.Fax
Email: Treating Doctor.E-mail

Signature:                                                                 Date: Miscellaneous.Date
Copy of report to: Copy To Doctors.Name and Address

Version 2.3 ZM 291019

Patient Referral
St Vincent's Northside Breast Health Centre specialises in routine breast screening, diagnostic assessment for all diseases of the breast and ongoing breast health care. Radiology services are integrated within our Breast Health Centre for ease of consultation and treatment, and breast cancer care. The St Vincent's Northside Breast Health Centre offers a comprehensive service with most patients receiving their results on the same day as their visit.
INFORMATION FOR REFERRING DOCTORS 
St Vincent’s Northside Breast Health Centre provides comprehensive breast screening, diagnostic assessment and breast cancer treatment. It is led by a dedicated and multidisciplinary team of breast cancer specialists who work together to optimise our patients’ breast health outcomes. 
Our Breast Health Centre team includes: 
. Breast Physicians 

. Breast Care Nurses
 
.  Mammographers and Sonographers 

. Women's Imaging Radiologists
 
. Breast and Endocrine Surgeons 

. Medical Oncologists

. Radiation Oncologists 

. Allied Health Professionals
INFORMATION FOR PATIENTS 		

YOUR APPOINTMENT
Should your symptoms alter significantly or you are worried about the timing of your appointment, please contact your referring Doctor who will contact the Breast Health Centre if a more urgent appointment is required.

Time:__________ am/pm   Date: ______________

Cost
As a private facility, there will be some out-of-pocket costs associated with our services. Please request further information specific to your referral when phoning for your appointment. 

Preparing for your appointment
• Please remember to bring this referral and any previous imaging and results you may have.
• It is a good idea to wear separate clothing (top and bottom) for your own comfort and convenience.
• Please do not wear powder or deodorant.
• Your visit may involve some waiting (occasionally up to four hours), so please bring along a book or electronic device to occupy your time.	

Contact details
Level 1, St Vincent's Northside Breast Health Centre
St Vincent's Private Hospital Northside
627 Rode Road CHERMSIDE 4032

Phone: (07) 3350 6633 Fax: (07) 3326 3636