Electronic Referral

For electronic referrals, please fill and submit the form below. If you would prefer to fill and fax, download our Fill & Fax form.

Please note that patients cannot be seen unless the referral has been made by a certified medical practitioner, registered with the Irish Medical Council. Patient may not self-refer. I declare that I am a a certified medical practitioner, registered with the Irish Medical Council.

Patient Details
Patient's Name*
Referral Details
Referring Doctor
Referring Doctor*
Provide an email address if you wish to receive confirmation of patient appointment time and date.
G.P. Name (if different from Referring Doctor)
Patient History
Referral Type *

Urgent Referral

Non - Urgent Referral

Clinical Findings

Location of Abnormality*

Please click relevant area on the diagram or choose from the list.

Breast Diagram
Left Underarm Left Nipple Left Outside Left Quad 1 Left Quad 2 Left Quad 3 Left Quad 4 Right Underarm Right Nipple Right Outside Right Quad 1 Right Quad 2 Right Quad 3 Right Quad 4 Breast Diagram
Leave this field empty