Please complete the form below to refer your patient to Breast Cancer Now’s Here for You service.
As a healthcare professional completing this form on behalf of a patient, you must read out each Patient Consent statement, asking the patient to confirm, and record that confirmation.
Breast Cancer Now will store your data for the purpose of contacting you as described above.
Data will be stored for up to 2 years. Once the referral is made, you can opt out at any time by
contacting hereforyou@breastcancernow.org or calling 0800 448 0822.
Patient details
Please provide First name
Please provide Last name
Please provide Address line1
Please provide Town/city
Please provide Postcode
Does the patient have an email address? *
Please provide Phone number
Only Numbers allowed in Preferred phone number
Can Breast Cancer Now leave a voice message on this number or a message if a family member answers the phone?
*
Can we say we are calling from Breast Cancer Now?
*
Please answer Can we say we are calling from Breast Cancer
Date of most recent diagnosis (DD/MM/YYYY) *
Invalid format (Expected format DD/MM/YYYY)
Equal opportunities monitoring
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Breast Cancer Now is committed to equality of opportunity for all. By providing this information, we can better meet our service users’ needs and make our services as accessible as possible.
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Please tell us about your patient's ethnic background:
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Additional requirements |
Does the patient require an interpreter?* |
Please specify if an interpreter is required
Are there any additional communication needs we should be aware of? (e.g. hearing difficulty, language needs)
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Healthcare professional information
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Healthcare professional name
* |
Please provide Healthcare professional name
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Email address*Enter valid email address
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Please provide Email Address
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Phone number |
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Hospital name * |
Please provide Hospital name
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