Referral form — New Zealand Familial Gastrointestinal Cancer Service

Referrer details

Name

Role

Practice

Address

Patient details

NHI number

First name

Middle name

Surname

Preferred name

Maiden name

Date of birth

Ethnicity

Iwi affiliation (if known)

Phone

Address

Referral details

If referring for colorectal cancer, does the patient meet the criteria for Category 3 individuals with a potentially high risk of colorectal cancer, as outlined in the referral criteria?

Referral criteria

Yes

Reason for referral

Relevant cancer/polyp history/previous endoscopy information (include ages at diagnoses)

Family history of cancer and/or gastrointestinal polyps (include ages at diagnoses)

Maternal

Paternal

Genetic testing

If the patient (or a first degree relative) has received genetic testing, provide details below.

Person 1

Testing provided for (name and relationship to patient)

Date the test was done

Gene name (if known)

Results

Genetics health service

Person 2

Testing provided for (name and relationship to patient)

Date the test was done

Gene name (if known)

Results

Genetics health service

Person 3

Testing provided for (name and relationship to patient)

Date the test was done

Gene name (if known)

Results

Genetics health service

Supporting documents

If you have any documents to support your referral, please email them to nzfgcs@adhb.govt.nz

Submitting this form implies consent from the patient to pass on their details and to be contacted by the New Zealand Familial Gastrointestinal Cancer Service.