SYDNEY BREAST CLINIC
LEVEL 12, 97-99 BATHURST ST, SYDNEY NSW 2000

FAX: 02 8251 4070 | EMAIL: INFO@SYDNEYBREASTCLINIC.COM.AU

TELEPHONE 02 8251 4000 FOR AN APPOINTMENT

		
DATE: 	INVESTIGATIONS MAY INCLUDE:	
PATIENT NAME: 	 +/- CLINICAL BREAST EXAMINATION	
DATE OF BIRTH: 	 +/- MAMMOGRAPHY/ TOMOGRAPHY	
ADDRESS: 	 +/- CONTRAST ENHANCED MAMMOGRAPHY	
PHONE NUMBER:                                 MOBILE: 	 +/- ULTRASOUND	
MEDICARE NO: 	 +/- FNA/ CORE BIOPSIES	

This service is for patients of all ages: 
1.	with breast symptoms,
2.	for follow up of existing breast disease or PROBLEMS, or 
3.	for screening of women who are potentially at an increased 
    	risk of developing breast cancer.

BONE MINERAL DENSITY TESTING (DEXA):  

This investigation is available to women of any age with risk factors for osteoporosis. 
If the patient is eligible to receive a Medicare rebate, please specify item number below:

ITEM NO: 	

CLINICAL NOTES:

	

FAMILY HISTORY / PAST HISTORY:

	

	
REFERRING DOCTOR DETAILS:	
	
NAME: 	
ADDRESS: 	
PHONE:                                                                                           PROVIDER #:                 	
SIGNATURE: