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Patient cancer family history referral form

Online referral form for patients to refer themselves to the Macmillan cancer family history referral service.

Guidance information for patients

Please read this guidance information prior to completing the form.

All forms will be returned to [email protected]

If any further advice is required, please also email [email protected]
or call 01642 282629

Patient details

Please complete all your details including your NHS number if known, and a current contact telephone number.

Referral reason

Please tick all that is appropriate and provide details if necessary.

Additional/relevant information

If you or a family member has a known gene fault, include details if known.

Cancer family history self-referral form for patients

Your details

Referral reason

Reason for referral

GP details

Additional useful information if available

Have you previously been seen in a genetics service?
Has any family member previously been seen in a genetics service?
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