GSH Breast Clinic Referral Form

Groote Schuur Hospital Specialist Breast Clinic Referral

This form is to be completed for all submissions to the Groote Schuur Hospital Diagnostic Breast Clinic. The form must be completed by a registered medical practitioner. Self referrals will not be accepted.
IMPORTANT INFORMATION

Please make sure you reed the information below before proceeding
We have moved to a new Booking Form. Please click the link below

Metro West Specialist Breast Clinic Referral
The purpose of the Groote Schuur Hospital Specialist Breast Clinic is to provide an easy access clinic for patients with symptoms of breast cancer. We cannot provide a general breast health clinic with our available resources.

To be seen at the clinic you need to have a symptom of breast cancer and need to reside in our drainage area.

To avoid disappointment for your patient please make sure your patient lives in our drainage area. Patients that reside in the Tygerberg Hospital drainage area should attend the Mamma clinic at Tygerberg Hospital, you can refer to the Tygerberg breast clinic using the VULA App. Patients that live in the Mitchells Plain Hospital drainage area should attend the clinic at Mitchells Pain Hospital (Link to booking Jotform). We cannot guarantee that patients from outside our drainage area will be seen at our clinic.

Please make sure you complete all the information required on the Jotform indicated by a red asterisk * If you do not complete all the fields the form will not allow you to continue to the booking calendar.

IF YOU ENCOUNTER ANY DIFFICULTY USING THE APPOINTMENT SYSTEM PLEASE EMAIL US ON breastsurgendo@gmail.com
Please make sure you you are familiar with the information above before proceeding*

I want to book an Appointment at the Groote Schuur Hospital Specialist Breast ClinicI want to book a Routine Mammogram AppointmentI want to book an Appointment at the High Risk Breast Clinic (This option is only available to doctors working in the breast unit and requires an access code)Internal Breast Unit Booking (Please note this option require an access code)
I hereby agree to receive updates and future information regarding the Groote Schuur Breast Clinic to the email address provided later*

YesNo

Appointment at the Groote Schuur Specialist Breast Clinic
Current age of patient*
Postcode (NOTE Enter postcode only, not full address)*

Referring Health Care Worker Information
Name referring health care worker*

PrefixFirst NameLast Name
Health Professional Council / South African Nursing Council Registration Number
Day hospital / Clinic / Hospital / Practice where the patient is referred from*
Email referring health care worker*
example@example.com
Phone Number referring health care worker*
Patient Information
Name of patient*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

DayMonthYear
Date
Do your patient have an existing PGWC clinic or hospital number?*
Please provide Hospital / Clinic Number*
Please provide ID number if available otherwise just write 'Not known' this will help us to locate a Groote Schuur Folder if the hospital number is not known*
Cellphone or home number of patient (NOTE If no contact number available use 021 123456)*

Referral information
Does your patient have any current breast symptoms?*

Yes, my patient have breast symptoms that needs referral

Breast Abscess

Patients with a breast abscess should not be referred to the breast clinic. Please refer your patient to your nearest facility where the abscess can be drained.

If you feel your patient should be seen because of concern please contact us by email at breastsurgendo@gmail.com or phone or Whatsapp us on 072 1751815. Please provide patient name, DOB, and hospital number of patients in all correspondence.

Breast Pain (Mastalgia)

Patients with breast pain as their only symptom is not seen at the Groote Schuur Breast Clinic. They can be treated by their primary health care provider. The treatment is not complex and these patients do not require any special investigations. Bilateral mastalgia is not an indication for a mammogram.

Most women (up to 7 in 10 women) develop breast pain at some stage in life develop breast pain at some stage in their life.

In about 2 in 3 women the pain develops in the days just before a period - cyclical breast pain.

In the remainder, the pain is not related to periods - non-cyclical.

The pain is often mild but in some women, it is more severe and can affect the quality of life. Treatment, over and above simple reassurance, may be necessary for these women.

Cyclical Breast Pain

Cyclical breast pain is common. It can occur at any age after periods start, but most commonly occurs between the ages of 30 and 50. It does not occur in women past the menopause when the periods have stopped.

What are the symptoms of cyclical breast pain?

In many women the symptoms are mild. Indeed, it can be considered normal to have some breast discomfort for a few days before a period. However, in some women, the pain can be severe and/or last longer - up to 1-2 weeks before a period. The 3-5 days prior to a period are usually the worst. The pain usually eases soon after a period starts. The severity can vary from month to month. Typically, the pain affects both breasts. It is usually worst in the upper and outer part of the breast and may travel down the arms. In patients with cyclical breast pain, their breasts may also become larger, tender, and slightly lumpy in the week or so before a period.

What causes cyclical breast pain?

It is thought that women with cyclical breast pain have breast tissue which is more sensitive than usual to the normal hormone changes that occur each month. It is not due to any hormone disease, or to any problem in the breast itself. It is not serious, but it can be a real nuisance.

What are the treatment options for cyclical breast pain?

No treatment may be needed if the symptoms are mild. Many women are reassured by knowing that cyclical breast pain is not a symptom of cancer or serious breast disease. The pain quite often settles by itself within 3-6 months but can come back from time to time.

If the pain is more severe, or for the times when it may flare up worse than usual, treatment options include the following:

Support the breasts. Wear a well-supporting bra when you have pain. Some women find that wearing a supporting bra 24 hours a day for the week before a period is helpful. It is best to avoid underwired bras. Wear a sports bra during exercise.

Painkillers such as paracetamol or ibuprofen. Take regularly on the days when the breasts are painful.

Topical ('rub-on') anti-inflammatory cream. For example, topical diclofenac or topical ibuprofen (Voltaren Gel).

Diet. Fatty acids may have a role in causing breast pain, so adjusting diet by reducing animal fats (such as butter, cream, and fatty meat) and increasing your intake of fresh fruit and vegetables can be helpful.
Evening primrose oil is often recommended as a treatment for breast pain. A dose of 1-2gms (2-4 tablets) of Evening Primrose oil each day for a period of 6 weeks is required before the benefit can be assessed. Improvement in the severity of cyclical and non-cyclical mastalgia is 58% and 38% respectively. If symptoms improve continue these tablets.

Non-cyclical Breast Pain

Breast pain can be present all the time, or 'come and go' in a random way. This type of breast pain is not related to periods and is most common in women over 40. The pain may be in just one breast and may be localized to one area in a breast. Sometimes the pain is felt all over one or both breasts. There are various causes. For example:

Pain coming from the breast tissue itself in the absence of any lumps, tumours, or other abnormality being detected. The reason why this type of pain occurs is not known.

Pain coming or radiating from the chest wall under the breast rather than the breast itself. Muscular or bony problems of the chest wall account for some cases.

Infection is a cause in a small number of cases.
Breast cancer is a very uncommon cause of breast pain (less than 5% of breast cancer cases)

What is the treatment for non-cyclical breast pain?

In many cases, the pain goes after a few months without any treatment. Anti-inflammatory painkillers such as ibuprofen may ease the pain. Topical anti-inflammatory cream (Voltaren gel) may also work. Other treatments may be appropriate, depending on whether a cause is found.

Breast Pain and Breast Cancer

Women with breast pain often worry that the pain is caused by breast cancer. But, the first symptom of breast cancer is usually a painless lump. If there is cancer associated with pain it is likely that another symptom such as a breast lump, breast enlargement, distortion of the skin, or redness of the skin will also be noticed or the pain will be unilateral and most likely focal in nature. These changes should be easily spotted on an assessment by a doctor.

Patients with breast pain and none of the symptoms of breast cancer are not seen in the Groote Schuur Breast Clinic. Remember for each inappropriate referral the waiting times for individuals with breast cancer will increase. We can only see a fixed amount of patients and effort needs to be focussed on symptoms associated with underlying breast cancer.

If you feel your patient should be seen because of concern please contact us by email at breastsurgendo@gmail.com or phone or Whatsapp us on 072 1751815. Please provide patient name, DOB, and hospital number of patients in all correspondence.

PLEASE NOTE

Make sure you select a date and time slot on the calendar. Once you have selected a time slot a blue box should appear below the calendar reading "You’ve selected 'time' AM on Friday / Wednesday and date" If you now hit submit your patient is booked.
Appointment (Orange) *Please choose date and time slot before proceeding* *
PLEASE NOTE

Please make sure you click Submit after selecting a date and time.

PLEASE NOTE

Make sure you select a date and time slot on the calendar. Once you have selected a time slot a blue box should appear below the calendar reading "You’ve selected 7:00/08h00 AM on Friday and date" If you now hit submit your patient is booked. All patients should be at the clinic before 07h00.
Appointment (Red1) *Please choose date and time slot before proceeding* *
PLEASE NOTE

Please make sure you click Submit after selecting a date and time.

PLEASE NOTE

Make sure you select a date and time slot on the calendar. Once you have selected a time slot a blue box should appear below the calendar reading "You’ve selected 7:00/08h00 AM on Friday and date" If you now hit submit your patient is booked. All patients should be at the clinic before 07h00.
Appointment (Red2) *Please choose date and time slot before proceeding* *
PLEASE NOTE

Please make sure you click Submit after selecting a date and time.

PLEASE NOTE

Make sure you select a date and time slot on the calendar. Once you have selected a time slot a blue box should appear below the calendar reading "You’ve selected 7:00/08h00 AM on Friday and date" If you now hit submit your patient is booked. All patients should be at the clinic before 07h00.
Appointment (Red3) *Please choose date and time slot before proceeding* *
PLEASE NOTE

Please make sure you click Submit after selecting a date and time.

PLEASE NOTE

Make sure you select a date and time slot on the calendar. Once you have selected a time slot a blue box should appear below the calendar reading "You’ve selected 7:00/08h00 AM on Friday and date" If you now hit submit your patient is booked. All patients should be at the clinic before 07h00.
Appointment (Green) *Please choose date and time slot before proceeding* *
PLEASE NOTE

Please make sure you click Submit after selecting a date and time.

PLEASE NOTE

Your patient lives in the Mitchells Plain drainage are. There is a Specialist Breast Clinic at Mitchells Plain Hospital on Monday mornings. Please use the relevant link to the Mitchells Plain Clinic, in the main website www.gshbreastendocrine.co.za or the Jotform link , to book an appointment at the Mitchells Plain Clinic.

Teenagers

Teenagers are not seen at the breast clinic unless they have a breast lump larger than 4 cm, roughly the size of a golfball, which might need excision. Small lumps in teenagers are almost always fibroadenomas. Lumps in teenagers do not need a biopsy or imaging, just a clinical follow-up. We suggest you follow your patient up in 3 months. If the lump is rapidly enlarging then contact us for an appointment, otherwise explain the benign nature of breast lumps in teenagers to your patient and discharge them to return if the lump continues to enlarge.

If you feel your patient should be seen because of concern please contact us by email at breastsurgendo@gmail.com or phone or Whatsapp us on 072 1751815. Please provide the patient name, DOB, and hospital number of your patient in all correspondence.

Routine Mammogram Booking

Your patient does not need to be seen at the Groote Schuur Hospital breast clinic.

A Routine Mammogram can be booked by clicking on the image below. You will automatically be re-directed to the mammogram booking page

Patient known with breast cancer and symptoms of distal metastasis

Patients known with breast cancer and symptoms of distal metastasis needs to be referred to Oncology at LE 33

Please contact 021 4044267 to arrange an appointment directly with the Breast Oncology Department

Bilateral Gynecomastia

Please use the guide below for the management of gynecomastia if the patient has a reason for referral according to the workup the patient can be referred by sending an email to breastsurgendo@gmail.com

Benign Conditions

Bilateral macromastia is a benign condition and is not seen in the breast clinic. Please refer to the website www.gshbreastendocrine.co.za for guidelines regarding macromastia management at Groote Schuur Hospital.

If you feel your patient should be seen because of concern please contact us by email at breastsurgendo@gmail.com or phone or Whatsapp us on 072 1751815. Please provide patient name, DOB, and hospital number of patients in all correspondence.

Access Code
Please enter access code to proceed*

Name of patient*

First NameLast Name
Folder number*
Phone Number of Patient*
Please enter a valid phone number.
Name of referring Doctor*

First NameLast Name
Contact number of the referring Doctor
Please enter a valid phone number.

Appointment High Risk Clinic (Just use the down arrow on the month button until a time appear that will be the next available date, you can select the time to complete the booking)*
PLEASE NOTE

Please make sure you click Submit after selecting a date and time.

If there is no time slot to select move to next month until the time box appears.

Remember the High Rik Clinic only runs every eight weeks.

Incorrect Access code
Incorrect password, please note the high-risk clinic is only for patients with a known high-risk genetic mutation or an IBIS risk calculator score of more than 8% 10-year risk or 30% lifetime risk. Please email us at breastsurgendo@gmail.com if you think your patient needs to be seen in the high-risk breast clinic.

Access code
Please enter access code to continue

Patient details
Patient name

First NameLast Name
Hospital / Clinic Number
ID Number if Hospital / Clinic number is not available

Incorrect access code

Should be Empty:

Groote Schuur Hospital Specialist Breast Clinic Referral

IMPORTANT INFORMATION

Appointment at the Groote Schuur Specialist Breast Clinic

Access Code

Incorrect Access code

Access code

Patient details

Incorrect access code