Genetic Services of WA 3Floor Agnes Walsh House 374 Bagot Road Sub - PDF document

Genetic Services of WA, 3Floor, Agnes Walsh House, 374 Bagot Road, Subiaco Western Australia 6008lephone (08) 6458 1603 Fax (08) 6458 1725 fcp@health.wa.gov.auwww.kemh.health.wa.gov.au/services/genetics amilial ancer rogramReferral orm Most cancers are nothereditaryand not everyone with a personal and/or family history of cancer is eligible for public genetic services. www.eviq.org.au providegenetic assessmentsto people with a personal and/or family history of cancersuggestive of hereditary cancer. Some people will also be eligible for genetic testingthrough our serviceTo ensure that services are offered appropriatelywe verify (where possible) reported personal and family history informationIt is important for your patient to be aware that the verificationprocess can be time consumingand may involve checking records on the Western ustralian C lease print thefinal page of this form (tient Information) and give to your patient. e will contactyour patient once we have received and triaged thereferral. Referring Doctor Details: Name : Provider Number: Practice name : Spec楡汩st G敮敲慬⁐r慣titi潮敲 Pr慣tic攠慤dr敳s P桯湥 䙡x: Ema楬: Patient Details:Given name(s): Surname: Maiden name: Date of Birth: Address: Mobile: Suburb: Postcode: : Email: Hospital URMN(if known): Gender: Male FemaltherCountry of Birth: Next of Kin: ATSI Status: Aboriginal Torres Strait Islander BothNeither Medicare Number: Ref:Expiry: Length of Referral: 3 Months12 MonthsIndefinite E-mail Post Does the patient need an interpreter ? YesLanguage: ______________________________ Does the patient have Jewish ancestry? Yes Details: ________________________________ �… No Has anyone in the family h ad genetic testin g or attended a genetic anywhere (worldwide) ? Yes Details: ________________________________ Is the patient suitable for a Telehealth consult? 奥s ††† †† Is t桥⁰ati敮t⁡w慲攠t桥

y 桡v 攠扥敮⁲ef敲r敤? 奥s††† †† ��Please send completed referral to the Central Referral Service Fax: 1300 365 056Genetic Services of WA, 3Floor, Agnes Walsh House, 374 Bagot Road, Subiaco Western Australia 6008lephone (08) 6458 1603 Fax (08) 6458 1725 fcp@health.wa.gov.auwww.kemh.health.wa.gov.au/services/geneticsUrgencyWe have limited capacity to expedite our services but will endeavour to do so if there is clinical indication (tick relevant situation and complete the table if applicable):imited life expectancPlease collect 2 x 5mL blood in EDTA and send to PathWest Department of Diagnostic Genomics at QEIIMedical Centre for DNA storage (it is not necessary to obtain consent for storage of DNA). Results of genetic testing could influence treatment decisions in the near future. Planned treatment Start date Surgery Chemotherapy Radiation Reason for Referral: Personal History: Please attach relevant documentation (e.g.histology reports, discharge summaries, specialist letters). Lack of relevant documentation may delay your patient’s assessment/testing. T ick Details (eg. type, year, treatment, specialist) Breast Cancer Ovarian Cancer Bowel Cancer Bowel Polyps O ther Cancer Family History:Please provide as much detailas possible for relativesand attachany available relevant documentation Name Relationship to patient (Maternal or Paternal) Cancer type Place of diagnosis or treatment DiagnosisAliveY/N Genetic Services of WA, 3Floor, Agnes Walsh House, 374 Bagot Road, Subiaco Western Australia 6008lephone (08) 6458 1603 Fax (08) 6458 1725 fcp@health.wa.gov.auwww.kemh.health.wa.gov.au/services/genetics Patient InformationAboutyour referral to the Familial Cancer Programat GSWAWho Genetic Services of Western ustraliaGenetic Services of Western Australia (GSWA)offers consultations forpeople with a hereditary condition (passed through families) and those concerned about

their risk of developing a hereditary condition. These services are provided by a range of staff, including clinical geneticists and genetic counsellors. Who might be referred to the Familial Cancer Program? Less than % of cancersare due t inheritedgene fault. GPs and specialistsrefer patients who are considered potentially high risk for developing a hereditary cancer. These may include breast, ovarian and bowel cancer, as well as bowel polyp disorders. What services does the Program offer?The Familial Cancer Program offers consultationsby telephone, videolinkappointments at metropolitan and outreach clinicWe provide:Information about inherited cancersAn assessment of your inherited cancerriskAn assessment of whether genetic testing an option for you or your familyRecommendations for screening and reducingyour riskSupport and counselling forpeoplewho are identified as highrisk.What is genetic testing?Genetic testing can be used to clarifyyour chance ofdeveloping or passing on a genetic conditionNot everyone is eligible forpublicgenetic estingIf genetic testing is an option, the advantages and limitations will be discussed with you before any decisions are made to proceed.Genetic testing is usually offered to a family member who has been diagnosed with cancer in the first instance; ia gene fault is identified, then other members without cancer can havetestingGenetic testing involves a blood test to analyse your DNA. No other invasive procedures are required.What happens next?Now that your doctor has referred you to GSWA, we will review the information provided and contact you by letter or telephone. To make an accurate assessment we often need additional information about yoursonal and/orfamilyhealth historyIf this is requiredwe will review the relevant records on the WA Cancer Registry or we will contactyouIf you have not heard from us within two months or you do not wish for your referral to proceplease contact uson the details belo