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

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

Name: Patient Demographics.Full Name   DOB: Patient Demographics.DOB 
Address: Patient Demographics.Full Address

I am referringPatient Demographics.First Name 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 Serv  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

Lump  Lump Lump
Thickening  Thickening Thickening
Dimple  Dimple Dimple
Pain  Pain Pain
Inflammation  Inflammation If Inflammation, ple
Discharge  Discharge If Discharge
Other If Other
Current Medications: Clinical Details.Medications - Current Regular
Allergies: Clinical Details.Allergies

Routine Appointments

Please indicate a suitable timeframe Timeframe
For URGENT appointments – please call our dedicated referring doctor line (doctors only)

Referring Doctor

Name: Treating Doctor.Name    Surgery: Practice.Name 
Address: Practice.Address 
Provider No: Treating Doctor.Provider Number   Telephone: Practice.Phone
Facsimile: Practice.Fax    Email: Treating Doctor.E-mail
Signature: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .	Date: Miscellaneous.Date
GP Referral  V3.0    July 2016                                          Refer to: WESLEY, Breast Clinic Referrals  RW4066000AD
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  V\3.0    July 2016