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
Does the patient have an email address? *
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?
*
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 * |
|
|
|