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.

I am providing this information on your behalf. Can you confirm that I have your permission to share the below personal details with Breast Cancer Now, and for Breast Cancer Now to store and use them to make contact by email and phone, providing personalised support and services available. *

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 or calling 0800 448 0822.

Patient details

First name*


Last name*


Address line 1 *


Address line 2

Town/city *


Postcode *


Does the patient have an email address? *

Preferred phone number *


Can Breast Cancer Now leave a voice message on this number or a message if a family member answers the phone? *

Diagnosis *

To make sure we provide appropriate support, please tick this box to confirm your patient’s most recent diagnosis *

Date of most recent diagnosis (DD/MM/YYYY) *

Equal opportunities monitoring
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.
Please tell us about your patient's ethnic background: *
Additional requirements
Does the patient require an interpreter?*


Are there any additional communication needs we should be aware of? (e.g. hearing difficulty, language needs)

Healthcare professional information

Healthcare professional name *
Email address* 
Phone number
Hospital name *