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*

Patient Address*

Gender* Female Male

Date of Birth* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910

Phone*

Mobile*

Insurance Details*

Referral Details

Date of Referral* 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000

Consultant's Name * Please Select David Gough Deirdre O'Hanlon Martin O'Sullivan Brian Whooley No Preference

Previous attendance at Bon Secours Specialist Breast Care Centre* Yes No

Referring Doctor

Referring Doctor*

Practice Address*

Phone*

Fax

Email

Provide an email address if you wish to receive confirmation of patient appointment time and date.

GP Medical Council Number*

G.P. Name (if different from Referring Doctor)

Certified medical practitioner.

Patient History

Previous Breast Disease* Yes No

Previous Mammogram* Yes No

Previous Mammogram Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1 2 3 4 5 6 7 8 9 10 11 12 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910

Where was your previous mammogram?

Referral Type *

Urgent Referral

• Suspicious Breast Lump
• Skin Tethering/contour change
• Nipple Inversion/Ulceration/Retraction
• Blood Stained Nipple Discharge
• Other

Non - Urgent Referral

• Clinically benign breast lump
• Recurrent cyst
• Nodularity/Breast pain
• Abscess/Mastitis
• Positive Family History
• Other

Clinical Findings

Location of Abnormality*

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

Breast Diagram

• Left Upper Outer Quadrant
• Left Lower Outer Quadrant
• Left Lower Inner Quadrant
• Left Upper Inner Quadrant
• Right Upper Inner Quadrant
• Right Lower Inner Quadrant
• Right Lower Outer Quadrant
• Right Upper Outer Quadrant
• Left Nipple
• Right Nipple
• Left Axilla
• Right Axilla
• Right Areola
• Left Areola

Clinical Findings and Additional Detail from Breast Examination*

Leave this field empty