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

PATIENT DETAILS:  	

Re: <PtFirstName> <PtSurname>             DOB: <PtDoB>
Address: <PtStreet>, <PtCity>, <PtState>, <PtPostcode>
Daytime phone: <PtPhoneH>    Mobile: <PtPhoneMob>	

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 ASSESSMENT>  : 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 (please indicate on illustration)>
Lump:  <Lump details>                    
Thickening:  <Thickening details>
Dimple:   <Dimple details>                   
Pain:   <Pain details>
Inflammation:   <Inflammation details>                
Discharge:   <Discharge details>

REFERRING DOCTOR:	
Name: <DrName>                                      Provider No. <DrProviderNo>
Practice name: <Practice>
Practice address: <UsrAddress>
Telephone: <UsrPhone>                                         Fax: <UsrFax>
Email: <DrEmail>

Signature:                                                                 Date:<TodaysDate>
Copy of report to: <Copy of report to>

Version 2.3 BP 29102019
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