PATIENT DISEASE SITE APPROPRIATE FOR REQUIRED FOR REFERRAL PROVIDE IF AVAILABLE REFERRAL Symptomatic of breast Referral to Breast Assessment All recent mammography and cancer and/or follow up Center breast ultrasound reports and on abnormal BAC Phone: 905-521-2100 pathology on previous biopsies. mammogram -> Referral Ext. 42497 to BAC BAC Fax : 905-381-70849o9084 Biopsy proven breast JCC Referral form U/S BREAST cancer History and Physical CT Scan Mammogram MRI Operative note Previous breast surgery notes Pathology and surgical pathology Bone Scan Discharge Summary ER/PR, HER 2Nu status Radiological suspicious JCC Referral form Associated consult notes mass/or biopsy proven History and Physical Discharge summary if CENTRAL NERVOUS lesion MRI applicable CT brain Labs SYSTEM Operative notes Pathology Suspicious EDAP referral esophageal/gastric mass/no tissue -> Referral to EDAP GASTROINTESTINAL Biopsy proven cancer or JCC Referral form Operative Note (esophagus, high grade dysplasia History and Physical Discharge summary stomach, Labs (CEA, CBC, LFT) CT Scan, upper GI series, colon/rectum, anus, Imaging for appropriate barium enema, U/S, ERCP, anatomy (endoscopy, liver scan, bone scan pancreas, liver, colonscopy, ERCP) Any associated consult notes biliary tract/gall Pathology bladder) Tumor markers: liver – AFP Pancreas-19-9 Neuroendocrine- Ki67% Referral Criteria: JCC Referral form Completed Family History GENETICS Cancer family history details Questionnaire (FHQ). () (Cancer Risk including age of diagnosis and Name(s) of relatives that have Assessment Clinic) primary site of cancer in been seen in our clinic relatives Previous consult notes or OR laboratory reports of cancer OBSP High Risk Screening genetic testing from patient Requisition and/or family members referrals for personal and/or family history of breast and/or ovarian cancer ( PATIENT DISEASE SITE APPROPRIATE FOR REQUIRED FOR REFERRAL PROVIDE IF AVAILABLE REFERRAL
DISEASE SITE PATIENT APPROPRIATE FOR REFERRAL REQUIRED FOR REFERRAL PROVIDE IF AVAILABLE BREAST Symptomatic of breast cancer and/or follow up on abnormal mammogram -> Referral to BAC Referral to Breast Assessment Center BAC Phone: 905-521-2100 Ext. 42497 BAC Fax : 905-381-70849o9084 All recent mammography and breast ultrasound reports and pathology on previous biopsies. Biopsy proven breast cancer JCC Referral form History and Physical Mammogram Operative note Pathology U/S CT Scan MRI Previous breast surgery notes and surgical pathology Bone Scan Discharge Summary ER/PR, HER 2Nu status CENTRAL NERVOUS SYSTEM Radiological suspicious mass/or biopsy proven lesion JCC Referral form History and Physical MRI CT brain Associated consult notes Discharge summary if applicable Labs Operative notes Pathology GASTROINTESTINAL (esophagus, stomach, colon/rectum, anus, pancreas, liver, biliary tract/gall bladder) Suspicious esophageal/gastric mass/no tissue -> Referral to EDAP EDAP referral Biopsy proven cancer or high grade dysplasia JCC Referral form History and Physical Labs (CEA, CBC, LFT) Imaging for appropriate anatomy (endoscopy, colonscopy, ERCP) Pathology Tumor markers: liver – AFP Pancreas-19-9 Neuroendocrine- Ki67% Operative Note Discharge summary CT Scan, upper GI series, barium enema, U/S, ERCP, liver scan, bone scan Any associated consult notes GENETICS (Cancer Risk Assessment Clinic) Referral Criteria: JCC Referral form Cancer family history details including age of diagnosis and primary site of cancer in relatives OR OBSP High Risk Screening Requisition referrals for personal and/or family history of breast and/or ovarian cancer ( Completed Family History Questionnaire (FHQ). () Name(s) of relatives that have been seen in our clinic Previous consult notes or laboratory reports of cancer genetic testing from patient and/or family members DISEASE SITE PATIENT APPROPRIATE FOR REFERRAL REQUIRED FOR REFERRAL PROVIDE IF AVAILABLE