Please complete the form below to refer your patient to Breast Cancer Now’s Here for You service.

As a healthcare professional completing this form on behalf of a patient, you must read out each Patient Consent statement, asking the patient to confirm, and record that confirmation.

I am providing this information on your behalf. Can you confirm that I have your permission to share the below personal details with Breast Cancer Now, and for Breast Cancer Now to store and use them to make contact by email and phone, providing personalised support and services available. *

Breast Cancer Now will store your data for the purpose of contacting you as described above. Data will be stored for up to 2 years. Once the referral is made, you can opt out at any time by contacting hereforyou@breastcancernow.org or calling 0800 448 0822.

Patient details

First name*

Please provide First name

Last name*

Please provide Last name

Address line 1 *

Please provide Address line1

Address line 2

Town/city *

Please provide Town/city

Postcode *

Please provide Postcode

Does the patient have an email address? *

Preferred phone number *

Please provide Phone number Only Numbers allowed in Preferred phone number

Can Breast Cancer Now leave a voice message on this number or a message if a family member answers the phone? *

Yes
No Please select Yes or No

Diagnosis *

Please select diagnosis

To make sure we provide appropriate support, please tick this box to confirm your patient’s most recent diagnosis *

Please confirm diagnosis

Date of most recent diagnosis (DD/MM/YYYY) *

Invalid format (Expected format DD/MM/YYYY)

Equal opportunities monitoring

Breast Cancer Now is committed to equality of opportunity for all. By providing this information, we can better meet our service users’ needs and make our services as accessible as possible.

Please tell us about your patient's ethnic background: *

Additional requirements

Does the patient require an interpreter?*

Yes

Please specify if an interpreter is required

Are there any additional communication needs we should be aware of? (e.g. hearing difficulty, language needs)

I confirm that providing this information complies with any applicable NHS data sharing protocols.
I understand and confirm that in providing this information on behalf of the person(s) named above I have sought written or verbal permission for their details to be shared with Breast Cancer Now, and for Breast Cancer Now to store and use them to make contact about the services indicated above. *

Healthcare professional information

Healthcare professional name *

Please provide Healthcare professional name

Email address*Enter valid email address

Please provide Email Address

Phone number

Hospital name *

Please provide Hospital name