CIBC Breast Assessment Centre Referral Form
The BAC Referral Form can be found here. <link to CIBC Breast Assessment Centre Referral Form>
For physicians wanting to refer their patient to the BAC, please see referral pathways below:
OBSP average risk screening – self referral. Patients can call 905-389-0101.
Non OBSP screening – BAC referral form <link to CIBC BAC Referral form-PDF>
Genetic Assessment & OBSP high risk screening – CCO – OBSP Requisition for High Risk Screening
Breast cancer surveillance – BAC referral form <link to CIBC BAC Referral form-PDF>
Screen detected abnormalities at the BAC – BAC will navigate patient through to diagnosis
Screen detected abnormalities at external imaging centres – <link to CIBC BAC Referral form-PDF>
Symptomatic assessment – BAC referral form <link to CIBC BAC Referral form-PDF>
For patients that require breast related services not offered at the BAC, please see the following options:
Juravinski Cancer Centre Patient Referral Form
If you are a physician whose patient was newly diagnosed with breast cancer at a facility other than the BAC and requires an oncology consultation, please click here for the JCC Referral Form
HNHB MRI Requisition & Clinical History 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, 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 ask you to complete the HNHB MRI Requisition <link to PDF> & Clinical History Form <link to OBSP High Risk MR Breast Consult Request Form>
- If your patient is recommended for a breast MRI in a radiology report from the BAC, you can use the HNHB MRI Requisition & Clinical History Form here <link to Breast MRI Consultation Form>to order.