Online Referrals Form

If you are a GP and would like to refer a private patient please complete and submit the form below.

Mr Anil DesaiMs Seema Seetharam
Patient Details:


MaleFemale




YesNo

Discrete breast or axillary lump in an adult (over 18)UlcerationSkin dimplingNipple eczemaRecent nipple retraction or distortion (less than 3 months)Blood-stained nipple dischargeBreast abscessInflammation that persists after antibioticsPersistently refilling or recurrent cystUnilateral discharge (not blood-stained)Intractable breast painAsymmetrical nodularity that persists at review after menstruationA patient whom the referring doctor considers to require a specialist opinion e.g. Minor or moderate degrees of persistent breast pain (no discrete palpable lesion)Persistent bilateral nipple discharge (not blood-stained)Abnormal mammogram / ultrasound scanOther




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