Prostate Cancer Nurse Specialist 
Referral Form

Please email form to:
FWLHD-ProstateCancerNurseConsultant@health.nsw.gov.au		

 PATIENTS WITH A CONFIRMED DIAGNOSIS OF PROSTATE CANCER CAN BE REFERRED DIRECTLY TO THE PROSTATE CANCER SPECIALIST NURSE (PCSN)
Patient referral criteria
•	Men with a confirmed diagnosis of prostate cancer
•	Must be a patient residing in FWLHD
•	Referrals to PCSN accepted from any source with patient consent 
•	The PCSN service is not an emergency service or a clinical procedure service	

PATIENT NAME:  <PtName>                   MRN (if available): _____________________

ADDRESS:  <PtAddress>

HOME PHONE: <PtPhoneH>	MOBILE PHONE: <PtPhoneMob>

DATE OF BIRTH: <PtDoB>		Patient Consent for Referral: <Patient Consent for Referral >
_____________________________________________________________________________

REFERRER:  NAME: <DrName>         POSITION: <Position?>
		  
PHONE NUMBER:	 <UsrPhone>	DATE of REFERRAL: <FormattedDate>

PRESENTING PROBLEM / REASON FOR REFERRAL:	

<Presenting Problem / Reason for referral?>

CURRENT MEDICAL HISTORY:	

<PMHActive>

PAST MEDICAL HISTORY:	

<PMHInactive>

CURRENT MEDICATIONS:	

<SelectedRx>

ALLERGIES:	

<Reactions>

Please insert / attach recent pathology results including PSA results.