BREAST RADIOLOGY REFERRAL FORM 1. Patient Information Full Name Date of Birth Address Phone Number Email Address 2. Clinical Indication Main Reason for Referral Symptomatic (Lump, Pain, Nipple Discharge, Skin Changes)Screening (Dense Tissue, Family History, High Risk)Follow-up / Post-Surgical MonitoringSecond Opinion on Previous Imaging Clinical History & Symptoms Previous Imaging Available? YesNo If yes, facility and approximate date 3. Examination(s) Requested Diagnostic Consultation3D Koning Vera Breast CTBreast UltrasoundImplant Integrity CheckGuided Biopsy Recommendation 4. Referrer Details Referrer Name GMC / Professional No. Clinic / Practice Name Referrer Signature Date of Referral
