Please complete the form below to refer your patient to Breast Cancer Now’s Living with Secondary Breast Cancer service I, the Healthcare professional named below, confirm that providing this information complies with any applicable NHS data-sharing protocols. NHS sharing protocol * 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 consent * Patient details Title - None -MrMrsMissMsMxDrProfessor First name * Last name * Does the patient have an email address? * Yes No Email address * Phone number * - Select -MobileLandline Number * Can we say we are from Breast Cancer Now if someone else answers the phone? * Yes No Can we leave a voicemail message if there is no answer? * Yes No Address line 1 * Address line 2 Town / city * Postcode * Diagnosis * - Select -PrimarySecondaryAbout the event Which service are you referring your patients to? * Face-to-face groups Online groups and Speakers live sessions Video programme All of the above 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 Locations and schedule * - Select -Aberdeen, 11am, second Wednesday of the monthBedfordshire, 11am, fourth Wednesday of the monthBelfast, 11am, third Friday of the monthBrighton, 11am, fourth Wednesday of the monthBristol, 11am, second Wednesday of the monthCardiff , 11am, third Friday of the monthCheltenham, 11am, fourth Monday of the monthCornwall (Truro) , 11am, first Thursday of the monthCoventry, 11am, second Thursday of the monthDorset (Poole) , 11am, first Thursday of the monthEdinburgh , 11am, last Monday of the monthGlasgow, 6pm, first Tuesday of the month Inverness, 11am, last Tuesday of the monthKendal, 11am, first Wednesday of the monthLanarkshire, 11am, fourth Wednesday of the monthLeeds, 11am, first Friday of the monthLeicester, 11am, fourth Monday of the monthLondon – Romford, 11am, first Thursday of the monthLondon – Ruislip, 11am, first Thursday of the monthLondon – Sutton, 11am, fourth Thursday of the monthMaidstone & Tunbridge Wells, 10.30am, first Tuesday of the monthManchester, 11am, third Wednesday of the monthMiddlesbrough , 11am, second Wednesday of the monthMilton Keynes, 11am, second Monday of the monthNorthampton, 11am, second Thursday of the monthNorth Lincolnshire (Scunthorpe) , 11am, third Thursday of the monthOxford, 11am, first Thursday of the monthSalisbury, 10.30am, third Wednesday of the monthSheffield, 11am, second Friday of the monthStaffordshire (Stoke), 11am, third Wednesday of the monthSurrey, Hampshire and Berkshire (Frimley), 11am, fourth Monday of the monthSwindon, 11am, second Wednesday of the monthTaunton, 11am, third Wednesday of the monthTorbay (Torquay), 11am, first Tuesday of the monthWrexham, 11am, first Friday of the monthYork, 11am, third Wednesday of the month Would you like to refer another patient? * - Select -YesNoPatient 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 consent * Patient details Title - None -MrMrsMissMsMxDrProfessor First name * Last name * Does the patient have an email address? * Yes No Email address * Phone number * - Select -MobileLandline Number * Can we say we are from Breast Cancer Now if someone else answers the phone? * Yes No Can we leave a voicemail message if there is no answer? * Yes No Address line 1 * Address line 2 Town / city * Postcode * Diagnosis * - Select -PrimarySecondaryAbout the event Which service are you referring your patients to? * Face-to-face groups Online groups and Speakers live sessions Video programme All of the above 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 Locations and schedule * - Select -Aberdeen, 11am, second Wednesday of the monthBelfast, 11am, third Friday of the monthBrighton, 11am, fourth Wednesday of the monthBristol, 11am, second Wednesday of the monthCardiff , 11am, third Friday of the monthCheltenham, 11am, fourth Monday of the monthCornwall (Truro) , 11am, first Thursday of the monthCoventry, 11am, second Thursday of the monthDorset (Poole) , 11am, first Thursday of the monthEdinburgh , 11am, last Monday of the monthGlasgow, 6pm, first Tuesday of the month Inverness, 11am, last Tuesday of the monthKendal, 11am, first Wednesday of the monthLanarkshire, 11am, fourth Wednesday of the monthLeeds, 11am, first Friday of the monthLeicester, 11am, fourth Monday of the monthLondon – Romford, 11am, first Thursday of the monthLondon – Ickenham, 11am, first Thursday of the monthLondon – Sutton, 11am, fourth Thursday of the monthMaidstone & Tunbridge Wells, 10.30am, first Tuesday of the monthManchester, 11am, third Wednesday of the monthMiddlesbrough , 11am, second Wednesday of the monthMilton Keynes, 11am, second Monday of the monthNorthampton, 11am, second Thursday of the monthNorth Lincolnshire (Scunthorpe) , 11am, third Thursday of the monthOxford, 11am, first Thursday of the monthSalisbury, 10.30am, third Wednesday of the monthSheffield, 11am, second Friday of the monthStaffordshire (Stoke), 11am, third Wednesday of the monthSurrey, Hampshire and Berkshire (Frimley), 11am, fourth Monday of the monthSwindon, 11am, second Wednesday of the monthTaunton, 11am, third Wednesday of the monthTorbay (Torquay), 11am, first Tuesday of the monthYork, 11am, third Wednesday of the month Would you like to refer another patient? * - Select -YesNoPatient 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 consent * Patient details Title - None -MrMrsMissMsMxDrProfessor First name * Last name * Does the patient have an email address? * Yes No Email address * Phone number * - Select -MobileLandline Number * Can we say we are from Breast Cancer Now if someone else answers the phone? * Yes No Can we leave a voicemail message if there is no answer? * Yes No Address line 1 * Address line 2 Town / city * Postcode * Diagnosis * - Select -PrimarySecondaryAbout the event Which service are you referring your patients to? * Face-to-face groups Online groups and Speakers live sessions Video programme All of the above 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 Locations and schedule * - Select -Aberdeen, 11am, second Wednesday of the monthBelfast, 11am, third Friday of the monthBrighton, 11am, fourth Wednesday of the monthBristol, 11am, second Wednesday of the monthCardiff , 11am, third Friday of the monthCheltenham, 11am, fourth Monday of the monthCornwall (Truro) , 11am, first Thursday of the monthCoventry, 11am, second Thursday of the monthDorset (Poole) , 11am, first Thursday of the monthEdinburgh , 11am, last Monday of the monthGlasgow, 6pm, first Tuesday of the month Inverness, 11am, last Tuesday of the monthKendal, 11am, first Wednesday of the monthLanarkshire, 11am, fourth Wednesday of the monthLeeds, 11am, first Friday of the monthLeicester, 11am, fourth Monday of the monthLondon – Romford, 11am, first Thursday of the monthLondon – Ruislip, 11am, first Thursday of the monthLondon – Sutton, 11am, fourth Thursday of the monthMaidstone & Tunbridge Wells, 10.30am, first Tuesday of the monthManchester, 11am, third Wednesday of the monthMiddlesbrough , 11am, second Wednesday of the monthMilton Keynes, 11am, second Monday of the monthNorthampton, 11am, second Thursday of the monthNorth Lincolnshire (Scunthorpe) , 11am, third Thursday of the monthOxford, 11am, first Thursday of the monthSalisbury, 10.30am, third Wednesday of the monthSheffield, 11am, second Friday of the monthStaffordshire (Stoke), 11am, third Wednesday of the monthSurrey, Hampshire and Berkshire (Frimley), 11am, fourth Monday of the monthSwindon, 11am, second Wednesday of the monthTaunton, 11am, third Wednesday of the monthTorbay (Torquay), 11am, first Tuesday of the monthYork, 11am, third Wednesday of the month Would you like to refer another patient? * - Select -YesNoPatient 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 consent * Patient details Title - None -MrMrsMissMsMxDrProfessor First name * Last name * Does the patient have an email address? * Yes No Email address * Phone number * - Select -MobileLandline Number * Can we say we are from Breast Cancer Now if someone else answers the phone? * Yes No Can we leave a voicemail message if there is no answer? * Yes No Address line 1 * Address line 2 Town / city * Postcode * Diagnosis * - Select -PrimarySecondaryAbout the event Which service are you referring your patients to? * Face-to-face groups Online groups and Speakers live sessions Video programme All of the above 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 Locations and schedule * - Select -Aberdeen, 11am, second Wednesday of the monthBelfast, 11am, third Friday of the monthBrighton, 11am, fourth Wednesday of the monthBristol, 11am, second Wednesday of the monthCardiff , 11am, third Friday of the monthCheltenham, 11am, fourth Monday of the monthCornwall (Truro) , 11am, first Thursday of the monthCoventry, 11am, second Thursday of the monthDorset (Poole) , 11am, first Thursday of the monthEdinburgh , 11am, last Monday of the monthGlasgow, 6pm, first Tuesday of the month Inverness, 11am, last Tuesday of the monthKendal, 11am, first Wednesday of the monthLanarkshire, 11am, fourth Wednesday of the monthLeeds, 11am, first Friday of the monthLeicester, 11am, fourth Monday of the monthLondon – Romford, 11am, first Thursday of the monthLondon – Ruislip, 11am, first Thursday of the monthLondon – Sutton, 11am, fourth Thursday of the monthMaidstone & Tunbridge Wells, 10.30am, first Tuesday of the monthManchester, 11am, third Wednesday of the monthMiddlesbrough , 11am, second Wednesday of the monthMilton Keynes, 11am, second Monday of the monthNorthampton, 11am, second Thursday of the monthNorth Lincolnshire (Scunthorpe) , 11am, third Thursday of the monthOxford, 11am, first Thursday of the monthSalisbury, 10.30am, third Wednesday of the monthSheffield, 11am, second Friday of the monthStaffordshire (Stoke), 11am, third Wednesday of the monthSurrey, Hampshire and Berkshire (Frimley), 11am, fourth Monday of the monthSwindon, 11am, second Wednesday of the monthTaunton, 11am, third Wednesday of the monthTorbay (Torquay), 11am, first Tuesday of the monthYork, 11am, third Wednesday of the month Would you like to refer another patient? * - Select -YesNoPatient 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 consent * Patient details Title - None -MrMrsMissMsMxDrProfessor First name * Last name * Does the patient have an email address? * Yes No Email address * Phone number * - Select -MobileLandline Number * Can we say we are from Breast Cancer Now if someone else answers the phone? * Yes No Can we leave a voicemail message if there is no answer? * Yes No Address line 1 * Address line 2 Town / city * Postcode * Diagnosis * - Select -PrimarySecondaryAbout the event Which service are you referring your patients to? * Face-to-face groups Online groups and Speakers live sessions Video programme All of the above 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 Locations and schedule * - Select -Aberdeen, 11am, second Wednesday of the monthBelfast, 11am, third Friday of the monthBrighton, 11am, fourth Wednesday of the monthBristol, 11am, second Wednesday of the monthCardiff , 11am, third Friday of the monthCheltenham, 11am, fourth Monday of the monthCornwall (Truro) , 11am, first Thursday of the monthCoventry, 11am, second Thursday of the monthDorset (Poole) , 11am, first Thursday of the monthEdinburgh , 11am, last Monday of the monthGlasgow, 6pm, first Tuesday of the month Inverness, 11am, last Tuesday of the monthKendal, 11am, first Wednesday of the monthLanarkshire, 11am, fourth Wednesday of the monthLeeds, 11am, first Friday of the monthLeicester, 11am, fourth Monday of the monthLondon – Romford, 11am, first Thursday of the monthLondon – Ruislip, 11am, first Thursday of the monthLondon – Sutton, 11am, fourth Thursday of the monthMaidstone & Tunbridge Wells, 10.30am, first Tuesday of the monthManchester, 11am, third Wednesday of the monthMiddlesbrough , 11am, second Wednesday of the monthMilton Keynes, 11am, second Monday of the monthNorthampton, 11am, second Thursday of the monthNorth Lincolnshire (Scunthorpe) , 11am, third Thursday of the monthOxford, 11am, first Thursday of the monthSalisbury, 10.30am, third Wednesday of the monthSheffield, 11am, second Friday of the monthStaffordshire (Stoke), 11am, third Wednesday of the monthSurrey, Hampshire and Berkshire (Frimley), 11am, fourth Monday of the monthSwindon, 11am, second Wednesday of the monthTaunton, 11am, third Wednesday of the monthTorbay (Torquay), 11am, first Tuesday of the monthYork, 11am, third Wednesday of the monthHealth Care Professional information Health Care Professional name * Email address * Phone number * Hospital name * Hospital Trust Would you have liked to be able to refer more patients? Yes No How many Submit
