Get the free HEREDITARY CANCER PROGRAM REFERRAL FORM - screeningbc

AGENCY CHART No. SURNAME Female HEREDITARY CANCER PROGRAM REFERRAL FORM Date of Referral: GIVEN NAME(S) Male BIRTHDATE (D/M/Y) HEALTH CARE PLAN No. (dd/mm/by) MAILING ADDRESS Referring Physician:

How to fill out hereditary cancer program referral

How to fill out hereditary cancer program referral:

1. Start by obtaining the necessary referral form from the hereditary cancer program or healthcare provider. This form is usually available online or can be requested from the program directly.
2. Fill in your personal information accurately, including your full name, date of birth, contact information, and any relevant medical history. Make sure to double-check the accuracy of this information to avoid any issues with the referral process.
3. Provide details about your family history of cancer. Include the types of cancer that have occurred in your immediate family members, such as parents, siblings, and children. Specify the age of each affected family member at the time of diagnosis.
4. Indicate any genetic testing that you or your family members have undergone. Include the type of test, the results, and the name of the laboratory that performed the testing if applicable.
5. Describe any additional pertinent medical information that would support your need for a hereditary cancer program referral. This may include any other relevant medical conditions or concerns.
6. If your healthcare provider is the one filling out the form, ensure that they provide their contact information and sign the referral.
7. Once you have completed the referral form, submit it to the hereditary cancer program either through mail, email, or their preferred method of submission. Make sure to follow any specific instructions provided by the program.
8. Keep a copy of the completed referral form for your records.

Who needs hereditary cancer program referral:

1. Individuals with a strong family history of cancer may benefit from a hereditary cancer program referral. This includes those who have multiple close relatives diagnosed with cancer, especially at a young age.
2. People who have been diagnosed with cancer themselves, particularly if they were diagnosed at an earlier age than expected for that type of cancer.
3. Individuals who have already undergone genetic testing for cancer-related genes and received positive results may need a hereditary cancer program referral to receive appropriate counseling and care.

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What is hereditary cancer program referral?

Hereditary cancer program referral is a process where individuals with a family history of cancer can be referred to a specialized program for genetic counseling and testing.

Who is required to file hereditary cancer program referral?

Healthcare providers or individuals with a known family history of cancer are required to file hereditary cancer program referral.

How to fill out hereditary cancer program referral?

To fill out hereditary cancer program referral, one must provide detailed information about their family history of cancer, personal medical history, and any genetic testing results.

What is the purpose of hereditary cancer program referral?

The purpose of hereditary cancer program referral is to identify individuals who may have an increased risk of developing cancer due to genetic factors, and to provide personalized prevention and treatment recommendations.

What information must be reported on hereditary cancer program referral?

Hereditary cancer program referral must include information about the individual's personal medical history, family history of cancer, and any previous genetic testing results.