Comprehensive Breast Program Referral Form

Phone: (603) 653-3500

Fax: (603) 653-3502

Comprehensive Breast Program

Referral Form

Patient Name: Last _______________________________ First _______________________________ MI ____________

DOB: _______________________________________________ DHMC MR#: _________________________________________

Address: _______________________________________________ City, ST: ________________________ Zip: ___________

Home #: __________________________ Work #: ____________________________ Cell #: ___________________________

Referring Provider: ___________________________________________________ Office #: _________________________

Contact Person: __________________________________________________________ Fax #: ___________________________

Staff Physician (if different from above): __________________________________ Office #: _________________________

Additional Info:

Management of Care:



Evaluate and treat at DHMC



We/the patient would like a 2

nd

opinion only



Please assume a subset of care:

Specify: _________________________________________________



Familial Cancer Program (please call (800) 251-0097)

Service/Appointment Requested

:

(check all that apply)





Mammogram/ultrasound & follow-up breast exam

Consultation with:

Breast Surgeon





Second opinion on mammograms

Plastic Surgeon





Biopsy (DHMC mammogram review required)

Medical Oncologist





Second opinion on films/scans

Radiation Oncologist



Genetic testing/counseling/risk assessment

(please call Familial Cancer Program (800) 251-0097)

:

Presenting Symptom/Diagnosis







Left breast

Right breast

Both



Abnormal mammogram

Please mark location on diagram 



Breast lump: Location: ________________ cm from nipple ___________



Skin changes (describe): _______________________________________



Nipple discharge

(circle color): Black/Brown Red Tan Green Yellow Milky Clear







New diagnosis of breast cancer:

L

R

Type _______________________





L



R

Prior diagnosis of breast cancer:

Year of diagnosis ____________

Type _____________________________



Family history of breast cancer:

Relation to patient _______________________________ Age at dx (if known) __________



Family history of ovarian cancer: Relation to patient _______________________________ Age at dx (if known) __________

Previous Treatment:

Dates (mm/yy) and Location(s) of Treatment:



Mammogram/Ultrasound (Important: list all facilities where last three

_________________________________________

mammograms have been done, and specify approximate dates)

_________________________________________



Biopsy – Diagnosis? _________________________________________

_________________________________________



Surgery - Type? _____________________________________________

_________________________________________



Chemotherapy ______________________________________________

_________________________________________



Radiation therapy ___________________________________________

_________________________________________



Other: ____________________________________________________

_________________________________________

Information required:

Send to:



All office and treatment notes, mammo and ultrasound reports,

Fax #: (603) 653-3502

pathology reports, labs – current/prior diagnosis



Films: mammograms (last 3 available), MRI’s, ultrasounds, scans

Attn: Mammo Review, DHMC,

One Medical Center Drive, Lebanon, NH 03756



Pathology slides for general surgery or medical oncology referrals

Attn: Wendy Wells, Pathology, DHMC,

One Medical Center Drive, Lebanon, NH 03756

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Rev. 4-28-11

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