The Wesley Breast Clinic Refer to: WESLEY, Breast Clinic Referrals (RW4066000AD)

... a multi-disciplinary centre providing comprehensive clinical and support services.

Name:<PtName>   
DOB: <PtDoB> 
Address: <PtAddress>

I am referring<PtFirstName> to: 

<Diagnostic Clinic>  Diagnostic Clinic (symptomatic women for assessment which may include mammography/tomography, ultrasound, needle sampling, MRI and surgical consultation as indicated)

<Screening Program>  Screening Program (mammography/tomography for asymptomatic women > 40 years)

<Core Biopsy>  Core Biopsy (films required prior to allocation of appointment)

<Familial Cancer Service>  Familial Cancer Service (undertaken in conjunction with the Diagnostic Service)

<Breast MRI Service>  Breast MRI Service (recent imaging is usually required prior to allocation of appointment)

Clinical Notes

<Clinical Notes: Lump>  Lump <If Lump, please describe>
<Thickening>  Thickening <If Thickening, please describe>
<Dimple>  Dimple <If Dimple, please describe>
<Pain>  Pain <If Pain, please describe>
<Inflammation>  Inflammation <If Inflammation, please describe>
<Discharge>  Discharge <If Discharge, please describe>
Other <If Other, please describe>
Current Medications: <SelectedRx>
Allergies: <Reactions>

Routine Appointments
Please indicate a suitable timeframe <Indicate a suitable timeframe for routine appts>
For URGENT appointments – please call our dedicated referring doctor line (doctors only)

Referring Doctor

Name: <DrName>    Surgery: <Practice> 
Address: <DrStreet> <DrCity> <DrState> <DrPostcode>  
Provider No:<DrProviderNo>   Telephone: <DrPhone>
Facsimile: <DrFax>    Email: <DrEmail>

Signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	Date: <Date >
GP Referral  V3.0 July 2016 

Information for your visit to the Clinic ...

To Make an Appointment

Telephone (07) 3232 7202 or Fax (07) 3217 8840, between 8.30am and 4.45pm Monday to Friday or email wesleybreastclinic@uchealth.com.au

Clinic Details

Location:	Level 1, The Sandford Jackson Building
The Wesley Hospital
Cnr Coronation Drive & Chasely Street, Auchenflower Qld 4066
(Adjacent to Auchenflower railway station, parking also available at The Wesley)

Postal Address:	PO Box 499, Toowong Qld 4066

Email:	wesleybreastclinic@uchealth.com.au

Your doctor has recommended that you use The Wesley Breast Clinic.  You may choose another provider but please discuss this with your doctor first.

Your Next Appointment

At . . . . . . . . . . . . . . . . . . . . . . . . .  . . . . . . . . .  am/pm on . . . . . . . . . . . . . . . . . . . . . . . .  .  . . . . 

Should your symptoms alter significantly or you are worried about the timing of your appointment please consult your referring Doctor who will contact the Clinic if a more urgent appointment is required.

General Information

Please ring us if you have any enquiries; if you wish to change your appointment; or if you are unable to attend.

Please remember to bring your previous mammograms (if you have any) . They are extremely important in the interpretation of your present films.

Please do not wear cream or talcum powder on your breast area . You may wear non-aerosol deodorant. Please avoid wearing perfume.

It is a good idea to wear separates.

Your visit will probably involve some waiting so you may like to bring something to help occupy your time.

If you experience tender, painful breasts before your period you may prefer not to come at that time.

GP Referral  V3.0    July 2016