Referral forms

Breast Cancer Suspicion Algorithm

Referral Guidelines


Referral Forms

Breast Imaging Referral Form

Referral for Surgical Consultation

Lymphedema Referral Form

Hereditary Breast Cancer Clinic Referral Form

Family history questionnaire for the Hereditary Cancer Clinic


No referral form needed for the following services. Please contact directly.

Referral for Nutrition Services – Ph: 204-235-3646 or fax request to 204-231-3839

Referral for Psychosocial Counselling – Ph: 204-258-1004 or fax request to 204-231-3839

If you have questions about our services or the referral process, please call the Centre from Monday to Friday (between 8:00am – 4:00 pm) at 204-235-3906 or Toll-free at 1-888-501-5219.

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