Please Fax or Email referral prior to appointment 
SYDNEY BREAST CLINIC REFERRAL / IMAGING REQUEST

Level 12, 97-99 Bathurst St Sydney NSW 2000

Phone: 1300 65 30 65 | Fax: 02 9283 1158 | Email: info@sydneybreastclinic.com.au

PATIENT::    
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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?		
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RISK ASSESSMENT <Risk Assessment? Yes or No?>   	BONE MINERAL DENSITY TESTING (DEXA)  <Bone Mineral Density Testing (Dexa)? Yes or No?>	
This service is for women who are potentially at an increased risk of developing breast cancer. Following categories may require increased surveillance; personal history of breast cancer, family history, previous histological biopsy, mammographically dense breasts, long term use of HRT.	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:	            DATE:	
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