BAC Referral Form

• OBSP average risk screening – self referral.  Average risk women between ages 50-74 with no history of breast cancer, breast implants and no current breast symptoms can call 905-389-0101 to book their own screening mammogram. A physician referral is not required.
• Non OBSP screening – For referral of women for breast cancer screening who are not eligible for the OBSP program due to age and/or medical history, please complete a BAC Referral Form
• Breast Cancer Surveillance – For referral of women with a person history of breast cancer, please complete a BAC Referral Form

• Genetic Assessment: For genetic counselling and risk assessment due to a personal and/or family history of breast and/or ovarian cancer, please complete the following requisition: CCO – OBSP Requisition for High Risk Screening and fax to 905-575-6316.
• Your patient may be asked to complete a Family History Questionnaire prior to booking an appointment.  A completed Family History Questionnaire can be included with new referrals, and this may expedite an appointment booking for your patient.
• If your patient is confirmed to be high risk and eligible for the OBSP High Risk Screening Program, the nurse navigators at the BAC will ask you to complete the HNHB MRI Requisition & Clinical History Form

• For patients who have had breast screening at the BAC and need additional imaging and/or biopsy in follow-up, we will navigate them through to a diagnosis. Should you have a question about an appointment booking for your patient, please call us at 905-521-2100 x42497
• For patients who have had breast screening at an external imaging centre, please complete a CIBC BAC Referral form.
• Please note that we will request copies of all previous imaging for your patient to be uploaded into our system before booking an appointment.  Patients can also pick up a CD with their images from the external imaging centre and deliver this to the BAC reception desk. This may help to expedite their imaging.

• For all patients with a breast symptom of concern, please complete a CIBC BAC Referral form. Please include ALL previous reports related to breast imaging, breast surgeries or consultations related to breast issues.
• Please note that we will request copies of all previous imaging for your patient to be uploaded into our system before booking an appointment. Patients can also pick up a CD with their images and deliver this to the BAC reception desk. This may help to expedite their imaging.

• For patients diagnosed with breast cancer following diagnostic assessment at the CIBC Breast Assessment Centre, we will expedite and organize an appointment with the next available breast surgeon. There are 1-2 surgical clinics held weekly at the BAC with a rotation of 4 breast surgeons. Please ensure you have checked off  'next available surgeon' on the CIBC BAC Referral form.
• For patients requiring a surgical, medical or radiation oncology consultation due to a new diagnosis of breast cancer made at an external facility or hospital, please click here for the Juravinski Cancer Centre New Patient Referral Form

MRI of the breast is available through the Diagnostic Imaging department at the Juravinski Hospital and Cancer Centre (JHCC). All referrals for breast MRI are reviewed and protocolled by JHCC breast radiologists prior to booking.

Indications for breast MRI include OBSP High Risk Screening, diagnostic assessment upon recommendation of radiologist, and cancer surveillance with recommendation of oncologist and/or breast surgeon.

• If your patient is in the OBSP High Risk Program, the nurse navigators at the BAC will send you the HNHB MRI Requisition & Breast MRI Clinical History Form
• If a radiologist has recommended that your patient have a breast MRI in a radiology report, you can use the HNHB MRI Requisition & Breast MRI Clinical History Form to order.

For more detailed information on Clinical Indications for Screening and Diagnostic Breast MRI, click here.

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