If you are a GP and would like to refer a private patient please complete and submit the form below. Referring to:Ms Seema SeethramMr Pawel Trapszo Date of referral Patient Details: Surname: First Name: Gender:MaleFemale DOB: Address: Mobile No: Tel day: Tel evening: First language: Interpreter required:YesNo Symptoms (please tick one or more) 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 Any other relevant information: GP Name: GP Surgery name and address:
