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Queensland Health
Referral to attend theBreast Cancer Family ClinicReferral to attend theBreast Cancer Family Clinic
Eligibility criteria to attend the Breast Cancer Family ClinicThe Breast Cancer Family Clinic accepts referrals for women aged 30 to 49 who meet the Cancer Australia high risk category criteria:
Two 1 degree or 2 degree relatives on one side of the family diagnosed with breast or ovarian cancer plus one or more of the following features on the same side of the family:
• additional relative(s) with breast or ovarian cancer• breast cancer diagnosed before the age of 40• bilateral breast cancer
Member of a family in which the presence of a high risk breast cancer gene mutation has been established. Women who are at potentially high risk of ovarian cancer.
• breast and ovarian cancer in the same women• Jewish ancestry• breast cancer in a male relative
Please return this form to Breast Cancer Family Clinic:
Post: PO Box 227, Virginia QLD 4014Fax: (07) 3350 7457Email: [email protected]
For further information please call (07) 3350 7425 or (07) 3350 7419 The Breast Cancer Family Clinic will contact the patient to arrange an appointment.
I wish to refer: Mrs/Ms/Miss
Address:
Suburb: Postcode:
Contact numbers: Home Work Mobile
Date of birth: Email:
for assessment and counselling, and for entry into the Breast Cancer Family Clinic. The above client meets the Cancer Australia high risk category criteria.
Family history details:
Referring GP details:
BSQ210520
