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Refer a Patient

To refer one of your patients to the Westmead BCI diagnostic clinic, please fill out and submit the form on this page.

A staff member from the Westmead bookings team will contact your patient to confirm their appointment.

 

Alternatively, you can download the form as a PDF and return to BCI either by email WSLHD-BCI-Referral@health.nsw.gov.au or fax 02 8890 8334.

Refer a Patient

Patient details

Date of Referral

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  • MM
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  • YYYY
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    • 1991
    • 1990

Date of Birth

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    • 31
  • MM
    • 1
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    • 3
    • 4
    • 5
    • 6
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    • 8
    • 9
    • 10
    • 11
    • 12
  • YYYY
    • 2016
    • 2015
    • 2014
    • 2013
    • 2012
    • 2011
    • 2010
    • 2009
    • 2008
    • 2007
    • 2006
    • 2005
    • 2004
    • 2003
    • 2002
    • 2001
    • 2000
    • 1999
    • 1998
    • 1997
    • 1996
    • 1995
    • 1994
    • 1993
    • 1992
    • 1991
    • 1990
    • 1989
    • 1988
    • 1987
    • 1986
    • 1985
    • 1984
    • 1983
    • 1982
    • 1981
    • 1980
    • 1979
    • 1978
    • 1977
    • 1976
    • 1975
    • 1974
    • 1973
    • 1972
    • 1971
    • 1970
    • 1969
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    • 1967
    • 1966
    • 1965
    • 1964
    • 1963
    • 1962
    • 1961
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    • 1953
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    • 1951
    • 1950
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    • 1948
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    • 1944
    • 1943
    • 1942
    • 1941
    • 1940
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    • 1938
    • 1937
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    • 1934
    • 1933
    • 1932
    • 1931
    • 1930
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    • 1926
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    • 1922
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    • 1900

Interpreter is required

PLEASE NOTE: WESTMEAD BREAST CANCER INSTITUTE WILL ONLY ACCEPT REFERRALS FOR PATIENTS WITH CONFIRMED OR REASONABLE SUSPICION OF CANCER. THIS INCLUDES:

  • At least one component of the ‘triple test’ positive (atypical/indeterminate, suspicious or malignant).
  • Conditions that require breast surgical referral;
    • Spontaneous unilateral, bloody or serous nipple discharge from a single duct
    • Eczematoid changes of the nipple-areolar skin which persist >1-2 weeks or do not respond to topical treatment
    • Inflammatory breast conditions that are not resolving after 2 weeks of antibiotic treatment
    • Cyst aspiration: residual lump or bloodstained fluid (not traumatic) or cyst persistently refills after aspiration
    • Test results that are inconsistent with other results and require additional investigation.

Checklist for Referral

Checklist for Referral

NOTE: Please check the relevant box for each row. If the checklist is not complete, a referral will not be triaged and the patient will not receive an appointment.

TRIPLE TEST RESULTS Negative Result Positive Result Details
Clinical Breast Examination
Imaging: Mammography+/- Ultrasound
Biopsy: Core Biopsy or FNA Cytology

Supporting Documents

Referring Doctor Details

NOTE: Referral request based on “The investigation of a new breast symptom: a guide for General Practitioners 2021” (refer to canceraustralia.gov.au)

The triple test is the recommended approach for investigation of breast changes.

When complete please email the referral to:
WSLHD-BCI-Referral@health.nsw.gov.au or Fax to: 02 8890 8334