SYDNEY BREAST CLINIC REFERRAL 1300 65 30 65

PATIENT::    
<PtDetails>
Tel: <PtPhoneH>
Mobile: <PtPhoneMob>
Medicare No: <PtMCNo>

PLEASE SELECT APPROPRIATE CLINIC

DIAGNOSTIC ASSESSMENT CLINIC              - <Diagnostic Assessment Clinic - Yes or No?>		
This service is for patients of all ages with a breast symptom or follow up of existing breast disease or problems.
		
INVESTIGATIONS MAY INCLUDE:		
+/-	          Clinical breast examination		
+/-	          Mammography / Tomography 		
+/-	          Ultrasound		
+/-	          Fine needle aspiration or core biopsy		
		
SYMPTOMATIC? <Symptomatic? Yes or No?>		
CLINICAL NOTES:		
<Symptomatic (clinical notes)>	

FAMILY HISTORY?		
<FamilyHx>		

BREAST SCREENING / RISK ASSESSMENT  <Breast Screening/Risk Assessment? Yes or No?>   	BONE MINERAL DENSITY TESTING (DEXA)  <Bone Mineral Density Testing (Dexa)? Yes or No?>	
This service is for women >40 years with no breast symptoms, or younger if they have potentially increased risk of developing breast cancer.
	This investigation is available to women of any age with risk factors for osteoporosis. If patient is eligible to receive a Medicare rebate please specify item number below:	
INVESTIGATIONS MAY INCLUDE:	Item No. <Item No?>	
		
+/-           Clinical breast examination;		
+/-	         Mammography / Tomography		
+/-	         Ultrasound		
+/-	         Fine needle aspiration or core biopsy		

PLEASE PROVIDE CLINICAL NOTES:

PLEASE PROVIDE CLINICAL NOTES:	

REFERRING DOCTOR DETAILS:		
<DrDetails>
<DrPhone>
Provider No: <DrProviderNo>