Living with secondary breast cancer - patient referral

I, the Healthcare professional named below, confirm that providing this information complies with any applicable NHS data-sharing protocols. *

Patient consent statements

As a healthcare professional completing this form on behalf of the patient named below, 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 these details with Breast Cancer Now, and for Breast Cancer Now to store and use them to make contact about the services indicated above. *

Can you confirm that if you no longer want Breast Cancer Now to use your information in this way, you understand that you can get in touch to withdraw permissions by contacting nrc@breastcancernow.org or calling 0345 077 1893. *

Patient details

Title

Select an option Mr Mrs Ms Miss Mx Dr Professor

First name *

Last name *

Does the patient have an email address? *

Select an option Yes No

Email address *

Phone number type *

Select an option Mobile Landline

Phone number *

Can we say we are from Breast Cancer Now if someone else answers the phone? *

Select an option Yes No

Can we leave a voicemail message if there is no answer? *

Select an option Yes No

Address

Patient's address * Add their postcode below to find their address.

Enter address manually

Address line 1 *

Address line 2

Address line 3

Town / city *

County

Postcode *

Country For example: United Kingdom

Diagnosis

Please confirm that the patient has secondary breast cancer *

About the event

Which service are you referring your patients to? *

Select an option Face-to-face groups Online groups and Speakers live sessions Video programme All of the above

Locations and schedule *

Select an option Aberdeen: 11am on the second Wednesday of the month Bedfordshire: 11am on the fourth Wednesday of the month Belfast: 11am on the third Friday of the month Birmingham: 11am on the third Thursday of each month Brighton: 11am on the fourth Wednesday of the month Bristol: 11am on the second Wednesday of the month Buckinghamshire: 11am on the third Monday of the month Cornwall (Truro): 11am on the third Thursday of the month Coventry: 11am on the second Thursday of the month Doncaster: 11am on the first Monday of the month Derry/Londonderry: 11am on the second Monday of the month Dorset (Poole): 11am on the first Thursday of the month Edinburgh: 11am on the last Monday of the month Exeter: 11am on the third Monday of each month Harrogate: 11am on the fourth Thursday of the month Kendal: 11am on the first Wednesday of the month Lanarkshire: 11am on the fourth Wednesday of the month Leeds: 11am on the first Friday of the month Leicester: 11am on the fourth Monday of the month London (Central): 11am on the third Thursday of the month London (Romford): 11am on the first Thursday of the month London (North London/Hertfordshire): 11am on the first Thursday of the month London (Sutton): 11am on the fourth Thursday of the month Maidstone & Tunbridge Wells: 10.30am on the first Tuesday of the month Manchester: 11am on the third Wednesday of the month Milton Keynes: 11am on the second Monday of the month Northampton: 11am on the second Thursday of the month Norwich: 11am on the second Friday of the month Orpington: 11am on the first Monday of each month Oxford: 11am on the third Thursday of the month Plymouth: 11am on the third Tuesday of each month Reading: 11am on the third Friday of the month Salisbury: 10.30am on the third Wednesday of the month Sheffield: 11am on the second Friday of the month Staffordshire (Stoke): 11am on the third Wednesday of the month Surrey, Hampshire and Berkshire (Frimley): 11am on the fourth Monday of the month Swindon: 11am on the first Wednesday of the month Taunton: 11am on the third Wednesday of the month Torbay (Torquay): 11am on the first Tuesday of the month Wrexham 11am on the First Friday of the month York: 11am on the third Wednesday of the month

Access fund

Access fund

Following a conversation, my patient would like to be contacted by phone to learn more about the Access Fund and how Breast Cancer Now may be able to help with travel costs

Would you like to refer a second patient? *

Select an option Yes No

Patient consent statements

As a healthcare professional completing this form on behalf of the patient named below, 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 these details with Breast Cancer Now, and for Breast Cancer Now to store and use them to make contact about the services indicated above. *

Can you confirm that if you no longer want Breast Cancer Now to use your information in this way, you understand that you can get in touch to withdraw permissions by contacting nrc@breastcancernow.org or calling 0345 077 1893. *

Second patient's details

Title

Select an option Mr Mrs Ms Miss Mx Dr Professor

First name *

Last name *

Does the patient have an email address? *

Select an option Yes No

Email address *

Phone number type *

Select an option Mobile Landline

Phone number *

Can we say we are from Breast Cancer Now if someone else answers the phone? *

Select an option Yes No

Can we leave a voicemail message if there is no answer? *

Select an option Yes No

Address

Address line 1 *

Address line 2

Address line 3

Town / city *

County

Postcode *

Country For example: United Kingdom

Diagnosis

Please confirm that the patient has secondary breast cancer *

About the event

Which service are you referring your patients to? *

Select an option Face-to-face groups Online groups and Speakers live sessions Video programme All of the above

Locations and schedule *

Select an option Aberdeen: 11am on the second Wednesday of the month Bedfordshire: 11am on the fourth Wednesday of the month Belfast: 11am on the third Friday of the month Birmingham: 11am on the third Thursday of each month Brighton: 11am on the fourth Wednesday of the month Bristol: 11am on the second Wednesday of the month Buckinghamshire: 11am on the third Monday of the month Cornwall (Truro): 11am on the third Thursday of the month Coventry: 11am on the second Thursday of the month Doncaster: 11am on the first Monday of the month Derry/Londonderry: 11am on the second Monday of the month Dorset (Poole): 11am on the first Thursday of the month Edinburgh: 11am on the last Monday of the month Exeter: 11am on the third Monday of each month Harrogate: 11am on the fourth Thursday of the month Kendal: 11am on the first Wednesday of the month Lanarkshire: 11am on the fourth Wednesday of the month Leeds: 11am on the first Friday of the month Leicester: 11am on the fourth Monday of the month London (Central): 11am on the third Thursday of the month London (Romford): 11am on the first Thursday of the month London (North London/Hertfordshire): 11am on the first Thursday of the month London (Sutton): 11am on the fourth Thursday of the month Maidstone & Tunbridge Wells: 10.30am on the first Tuesday of the month Manchester: 11am on the third Wednesday of the month Milton Keynes: 11am on the second Monday of the month Northampton: 11am on the second Thursday of the month Norwich: 11am on the second Friday of the month Orpington: 11am on the first Monday of each month Oxford: 11am on the third Thursday of the month Plymouth: 11am on the third Tuesday of each month Reading: 11am on the third Friday of the month Salisbury: 10.30am on the third Wednesday of the month Sheffield: 11am on the second Friday of the month Staffordshire (Stoke): 11am on the third Wednesday of the month Surrey, Hampshire and Berkshire (Frimley): 11am on the fourth Monday of the month Swindon: 11am on the first Wednesday of the month Taunton: 11am on the third Wednesday of the month Torbay (Torquay): 11am on the first Tuesday of the month Wrexham 11am on the First Friday of the month York: 11am on the third Wednesday of the month

Access fund

Access fund

Following a conversation, my patient would like to be contacted by phone to learn more about the Access Fund and how Breast Cancer Now may be able to help with travel costs

Would you like to refer a third patient? *

Select an option Yes No

Patient consent statements

As a healthcare professional completing this form on behalf of the patient named below, 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 these details with Breast Cancer Now, and for Breast Cancer Now to store and use them to make contact about the services indicated above. *

Can you confirm that if you no longer want Breast Cancer Now to use your information in this way, you understand that you can get in touch to withdraw permissions by contacting nrc@breastcancernow.org or calling 0345 077 1893. *

Third patient's details

Title

Select an option Mr Mrs Ms Miss Mx Dr Professor

First name *

Last name *

Does the patient have an email address? *

Select an option Yes No

Email address *

Phone number type *

Select an option Mobile Landline

Phone number *

Can we say we are from Breast Cancer Now if someone else answers the phone? *

Select an option Yes No

Can we leave a voicemail message if there is no answer? *

Select an option Yes No

Address

Address line 1 *

Address line 2

Address line 3

Town / city *

County

Postcode *

Country For example: United Kingdom

Diagnosis

Please confirm that the patient has secondary breast cancer *

About the event

Which service are you referring your patients to? *

Select an option Face-to-face groups Online groups and Speakers live sessions Video programme All of the above

Locations and schedule *

Select an option Aberdeen: 11am on the second Wednesday of the month Bedfordshire: 11am on the fourth Wednesday of the month Belfast: 11am on the third Friday of the month Birmingham: 11am on the third Thursday of each month Brighton: 11am on the fourth Wednesday of the month Bristol: 11am on the second Wednesday of the month Buckinghamshire: 11am on the third Monday of the month Cornwall (Truro): 11am on the third Thursday of the month Coventry: 11am on the second Thursday of the month Doncaster: 11am on the first Monday of the month Derry/Londonderry: 11am on the second Monday of the month Dorset (Poole): 11am on the first Thursday of the month Edinburgh: 11am on the last Monday of the month Exeter: 11am on the third Monday of each month Harrogate: 11am on the fourth Thursday of the month Kendal: 11am on the first Wednesday of the month Lanarkshire: 11am on the fourth Wednesday of the month Leeds: 11am on the first Friday of the month Leicester: 11am on the fourth Monday of the month London (Central): 11am on the third Thursday of the month London (Romford): 11am on the first Thursday of the month London (North London/Hertfordshire): 11am on the first Thursday of the month London (Sutton): 11am on the fourth Thursday of the month Maidstone & Tunbridge Wells: 10.30am on the first Tuesday of the month Manchester: 11am on the third Wednesday of the month Milton Keynes: 11am on the second Monday of the month Northampton: 11am on the second Thursday of the month Norwich: 11am on the second Friday of the month Orpington: 11am on the first Monday of each month Oxford: 11am on the third Thursday of the month Plymouth: 11am on the third Tuesday of each month Reading: 11am on the third Friday of the month Salisbury: 10.30am on the third Wednesday of the month Sheffield: 11am on the second Friday of the month Staffordshire (Stoke): 11am on the third Wednesday of the month Surrey, Hampshire and Berkshire (Frimley): 11am on the fourth Monday of the month Swindon: 11am on the first Wednesday of the month Taunton: 11am on the third Wednesday of the month Torbay (Torquay): 11am on the first Tuesday of the month Wrexham 11am on the First Friday of the month York: 11am on the third Wednesday of the month

Access fund

Access fund

Following a conversation, my patient would like to be contacted by phone to learn more about the Access Fund and how Breast Cancer Now may be able to help with travel costs

Would you like to refer a fourth patient? *

Select an option Yes No

Patient consent statements

As a healthcare professional completing this form on behalf of the patient named below, 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 these details with Breast Cancer Now, and for Breast Cancer Now to store and use them to make contact about the services indicated above. *

Can you confirm that if you no longer want Breast Cancer Now to use your information in this way, you understand that you can get in touch to withdraw permissions by contacting nrc@breastcancernow.org or calling 0345 077 1893. *

Fourth patient's details

Title

Select an option Mr Mrs Ms Miss Mx Dr Professor

First name *

Last name *

Does the patient have an email address? *

Select an option Yes No

Email address *

Phone number type *

Select an option Mobile Landline

Phone number *

Can we say we are from Breast Cancer Now if someone else answers the phone? *

Select an option Yes No

Can we leave a voicemail message if there is no answer? *

Select an option Yes No

Address

Address line 1 *

Address line 2

Address line 3

Town / city *

County

Postcode *

Country For example: United Kingdom

Diagnosis

Please confirm that the patient has secondary breast cancer *

About the event

Which service are you referring your patients to? *

Select an option Face-to-face groups Online groups and Speakers live sessions Video programme All of the above

Locations and schedule *

Select an option Aberdeen: 11am on the second Wednesday of the month Bedfordshire: 11am on the fourth Wednesday of the month Belfast: 11am on the third Friday of the month Birmingham: 11am on the third Thursday of each month Brighton: 11am on the fourth Wednesday of the month Bristol: 11am on the second Wednesday of the month Buckinghamshire: 11am on the third Monday of the month Cornwall (Truro): 11am on the third Thursday of the month Coventry: 11am on the second Thursday of the month Doncaster: 11am on the first Monday of the month Derry/Londonderry: 11am on the second Monday of the month Dorset (Poole): 11am on the first Thursday of the month Edinburgh: 11am on the last Monday of the month Exeter: 11am on the third Monday of each month Harrogate: 11am on the fourth Thursday of the month Kendal: 11am on the first Wednesday of the month Lanarkshire: 11am on the fourth Wednesday of the month Leeds: 11am on the first Friday of the month Leicester: 11am on the fourth Monday of the month London (Central): 11am on the third Thursday of the month London (Romford): 11am on the first Thursday of the month London (North London/Hertfordshire): 11am on the first Thursday of the month London (Sutton): 11am on the fourth Thursday of the month Maidstone & Tunbridge Wells: 10.30am on the first Tuesday of the month Manchester: 11am on the third Wednesday of the month Milton Keynes: 11am on the second Monday of the month Northampton: 11am on the second Thursday of the month Norwich: 11am on the second Friday of the month Orpington: 11am on the first Monday of each month Oxford: 11am on the third Thursday of the month Plymouth: 11am on the third Tuesday of each month Reading: 11am on the third Friday of the month Salisbury: 10.30am on the third Wednesday of the month Sheffield: 11am on the second Friday of the month Staffordshire (Stoke): 11am on the third Wednesday of the month Surrey, Hampshire and Berkshire (Frimley): 11am on the fourth Monday of the month Swindon: 11am on the first Wednesday of the month Taunton: 11am on the third Wednesday of the month Torbay (Torquay): 11am on the first Tuesday of the month Wrexham 11am on the First Friday of the month York: 11am on the third Wednesday of the month

Access fund

Access fund

Following a conversation, my patient would like to be contacted by phone to learn more about the Access Fund and how Breast Cancer Now may be able to help with travel costs

Would you like to refer a fifth patient? *

Select an option Yes No

Patient consent statements

As a healthcare professional completing this form on behalf of the patient named below, 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 these details with Breast Cancer Now, and for Breast Cancer Now to store and use them to make contact about the services indicated above. *

Can you confirm that if you no longer want Breast Cancer Now to use your information in this way, you understand that you can get in touch to withdraw permissions by contacting nrc@breastcancernow.org or calling 0345 077 1893. *

Fifth patient's details

Title

Select an option Mr Mrs Ms Miss Mx Dr Professor

First name *

Last name *

Does the patient have an email address? *

Select an option Yes No

Email address *

Phone number type *

Select an option Mobile Landline

Phone number *

Can we say we are from Breast Cancer Now if someone else answers the phone? *

Select an option Yes No

Can we leave a voicemail message if there is no answer? *

Select an option Yes No

Address

Address line 1 *

Address line 2

Address line 3

Town / city *

County

Postcode *

Country For example: United Kingdom

Diagnosis

Please confirm that the patient has secondary breast cancer *

About the event

Which service are you referring your patients to? *

Select an option Face-to-face groups Online groups and Speakers live sessions Video programme All of the above

Locations and schedule *

Select an option Aberdeen: 11am on the second Wednesday of the month Bedfordshire: 11am on the fourth Wednesday of the month Belfast: 11am on the third Friday of the month Birmingham: 11am on the third Thursday of each month Brighton: 11am on the fourth Wednesday of the month Bristol: 11am on the second Wednesday of the month Buckinghamshire: 11am on the third Monday of the month Cornwall (Truro): 11am on the third Thursday of the month Coventry: 11am on the second Thursday of the month Doncaster: 11am on the first Monday of the month Derry/Londonderry: 11am on the second Monday of the month Dorset (Poole): 11am on the first Thursday of the month Edinburgh: 11am on the last Monday of the month Exeter: 11am on the third Monday of each month Harrogate: 11am on the fourth Thursday of the month Kendal: 11am on the first Wednesday of the month Lanarkshire: 11am on the fourth Wednesday of the month Leeds: 11am on the first Friday of the month Leicester: 11am on the fourth Monday of the month London (Central): 11am on the third Thursday of the month London (Romford): 11am on the first Thursday of the month London (North London/Hertfordshire): 11am on the first Thursday of the month London (Sutton): 11am on the fourth Thursday of the month Maidstone & Tunbridge Wells: 10.30am on the first Tuesday of the month Manchester: 11am on the third Wednesday of the month Milton Keynes: 11am on the second Monday of the month Northampton: 11am on the second Thursday of the month Norwich: 11am on the second Friday of the month Orpington: 11am on the first Monday of each month Oxford: 11am on the third Thursday of the month Plymouth: 11am on the third Tuesday of each month Reading: 11am on the third Friday of the month Salisbury: 10.30am on the third Wednesday of the month Sheffield: 11am on the second Friday of the month Staffordshire (Stoke): 11am on the third Wednesday of the month Surrey, Hampshire and Berkshire (Frimley): 11am on the fourth Monday of the month Swindon: 11am on the first Wednesday of the month Taunton: 11am on the third Wednesday of the month Torbay (Torquay): 11am on the first Tuesday of the month Wrexham 11am on the First Friday of the month York: 11am on the third Wednesday of the month

Access fund

Access fund

Following a conversation, my patient would like to be contacted by phone to learn more about the Access Fund and how Breast Cancer Now may be able to help with travel costs

Healthcare professional information

Healthcare professional name *

Email address *

Phone number *

Hospital name *

Hospital Trust *