REFERRAL FOR CANCER GENETICS CONSULTATION

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REFERRAL&FOR&CANCER&GENETICS&CONSULTATION&
PATIENT&INFORMATION&(or$affix$patient$label)&
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NAME:&___________________________________________________&D.O.B.&____________________&
Male((((((((((((((((((Female&(
Mailing&Address:&______________________________________________________________________&
____________________________________________________________________________________&
Telephone&#:&_________________________________----------------------(&
Health&Card&Number&_______________________________________&&
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REASON&FOR&REFERRAL:&________________________________________________________________&
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Has&the&patient&been&diagnosed&with&cancer?&./ ((((((012((
Please$specify:$__________________________________________________________________&______&
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FAMILY&HISTORY&
$(Please'attach'second'page'if'needed)'
Name&(if&available)&and&
relationship&to&patient&
3$4"4(567"(89":(;6<"=76>(6?7<@(
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Primary&site&
3$4"4(A="6%<@(
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Age&at&
diagnosis&
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REFFERING&PHYSICIAN&__________________________________________________________________&&
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Telephone#:____________________________________&Fax&#:_________________________________&
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SIGNATURE:&__________________________________________________________________________&
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! The&family&history&will&be&assessed&by&the&genetics&clinic&to&evaluate&whether&the&patient&is&eligible&for&a&
genetic&assessment.&
! &A&family&history&questionnaire&will&be&sent&to&the&patient&and&must&be&completed&and&returned&prior&to&
booking&an&appointment.&&
! Genetic&testing&may&or&may&not&be&offered&in&the&course&of&a&genetics&consultation,&pending&eligibility.&
CANCER&RISK&ASSESSMENT&CLINIC&
Juravinski&Cancer&Centre&
699&Concession&Street&
Hamilton,&Ontario&L8V&5C2&
T:&905^521^2100&Ext.&64636&
Fax&(905)&575^6316&(referral&fax)&