Sign in
Donate

Enter the terms you wish to search for.

Home
Information & support
- Have I got breast cancer?
  Signs and symptoms of breast cancer
  
  What to expect at appointments
  
  Benign breast conditions
  
  More
  
  Facing breast cancer
  Diagnosed with breast cancer
  
  Going through treatment
  
  Life after treatment
  
  More
  
  Secondary breast cancer
  Diagnosis
  
  Treatments for secondary breast cancer
  
  Living with secondary breast cancer
  
  Spot the signs and symptoms of secondary breast cancer
  
  More
  
  Support for you
  Register for online services
  
  Contact our nurses
  
  Download and order publications
  
  For Healthcare professionals
  
  Breast cancer glossary
Research
- About our research
  What is our research about?
  
  Secondary breast cancer
  
  Our research achievements
  
  Research projects
  Generations study
  
  Male breast cancer study
  
  Our tissue bank
  
  Our research centre
  
  More
  
  Information for researchers
  Apply for funding
  
  Our advisory committees
  
  Research policies
  
  How we award grants
  
  Apply to our tissue bank
  
  Research news
Get involved
- Take on a sports challenge
  Charity runs
  
  Charity bike rides
  
  Charity walks
  
  More
  
  Do your own fundraising
  Afternoon Tea
  
  Take part in wear it pink
  
  Golf for Breast Cancer Now
  
  More
  
  Campaign with us
  Press play on funding for breast cancer
  
  The Unsurvivors
  
  Sign up for campaign updates
  
  More
  
  Volunteer with us
  Support others with breast cancer
  
  Help raise money
  
  Share your views and experience
  
  More
  
  Join a special event
  Carols by Candlelight
  
  The Show London
  
  The Show Scotland
  
  More
  
  Donate
  Corporate partnerships
  
  Give in memory
  
  Sponsor a Nurse
  
  More
Near you
Forum
About us
- About us
  News and personal stories
  
  More
  
  Our organisation
  Our work in secondary breast cancer
  
  Our work in Scotland
  
  Our work in Wales
  
  Media
  Press releases
  
  Statements
  
  Facts and statistics
  
  More
  
  Contact us
  
  Work with us
Donate

Home

Here for You - Patient referral form

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.

1 Start 2 Complete

Patient details

First name *

Last name

Address line 1 *

Address line 2

Town/city *

Postcode *

Email address *

Preferred phone number *

Can Breast Cancer Now leave a voice message on this number? *

Yes

No

Can we say we are calling from Breast Cancer Now if we have to leave a message or if a family member answers the phone? *

Yes

No

Date of diagnosis *

Diagnosis *

Equal opportunities monitoring

Breast Cancer Now is committed to equality of opportunity for all. This information is not compulsory but if you can indicate your patient’s ethnic background here, 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:

White

Asian or Asian British

Mixed

Black or black British

Other ethnic groups

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

Would you like to refer another patient? *

Patient details

First name *

Last name

Address line 1 *

Address line 2

Town/city *

Postcode *

Email address *

Preferred phone number *

Can Breast Cancer Now leave a voice message on this number? *

Yes

No

Can we say we are calling from Breast Cancer Now if we have to leave a message or if a family member answers the phone? *

Yes

No

Date of diagnosis *

Diagnosis *

Equal opportunities monitoring

Breast Cancer Now is committed to equality of opportunity for all. This information is not compulsory but if you can indicate your patient’s ethnic background here, 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:

White

Asian or Asian British

Mixed

Black or black British

Other ethnic groups

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

Would you like to refer another patient? *

Patient details

First name *

Last name

Address line 1 *

Address line 2

Town/city *

Postcode *

Email address *

Preferred phone number *

Can Breast Cancer Now leave a voice message on this number? *

Yes

No

Can we say we are calling from Breast Cancer Now if we have to leave a message or if a family member answers the phone? *

Yes

No

Date of diagnosis *

Diagnosis *

Equal opportunities monitoring

Breast Cancer Now is committed to equality of opportunity for all. This information is not compulsory but if you can indicate your patient’s ethnic background here, 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:

White

Asian or Asian British

Mixed

Black or black British

Other ethnic groups

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

Would you like to refer another patient?

Patient details

First name *

Last name

Address line 1 *

Address line 2

Town/city *

Postcode *

Email address *

Preferred phone number *

Can Breast Cancer Now leave a voice message on this number? *

Yes

No

Can we say we are calling from Breast Cancer Now if we have to leave a message or if a family member answers the phone? *

Yes

No

Date of diagnosis *

Diagnosis *

Equal opportunities monitoring

Breast Cancer Now is committed to equality of opportunity for all. This information is not compulsory but if you can indicate your patient’s ethnic background here, 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:

White

Asian or Asian British

Mixed

Black or black British

Other ethnic groups

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

Would you like to refer another patient? *

Patient details

First name *

Last name

Address line 1 *

Address line 2

Town/city *

Postcode *

Email address *

Preferred phone number *

Can Breast Cancer Now leave a voice message on this number? *

Yes

No

Can we say we are calling from Breast Cancer Now if we have to leave a message or if a family member answers the phone? *

Yes

No

Date of diagnosis *

Diagnosis *

Equal opportunities monitoring

Breast Cancer Now is committed to equality of opportunity for all. This information is not compulsory but if you can indicate your patient’s ethnic background here, 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:

Asian or Asian British

White

Black or black British

Mixed

Other ethnic groups

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

Patient(s) Consent statements

I confirm that providing this information complies with any applicable NHS data sharing protocols.

The patient(s) has confirmed that the above information is correct.

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.

If the person(s) named above no longer wants Breast Cancer Now to use their information in this way, I understand that I can get in touch to withdraw their permissions by contacting nrc@breastcancernow.org or calling 0345 077 1893.

Healthcare professional information

Healthcare professional name *

Email address *

Phone number *

Hospital name *

Hospital Trust *

Stay in touch

We’d love to keep in touch about news, events and how you can get involved. To hear from us, enter your email address below.

Email address *

Connect with us

Twitter
Facebook
Instagram
YouTube

Privacy & Cookies policy
Medical disclaimer
Terms and conditions
Contact us
Where we fundraise
Complaints
Becca app
Work with us

Formed by the merger of

Breast Cancer Now is a company limited by guarantee registered in England (9347608) and a charity registered in England and Wales (1160558), Scotland (SC045584) and Isle of Man (1200). Registered Office: Fifth Floor, Ibex House, 42-47 Minories, London EC3N 1DY.