Refer a patient

Health Care Professional (HCP) - Patient Referral to RCA navigation support service  

A rare cancer diagnosis can turn a person’s world upside down. It can leave them feeling lost, isolated, and looking for information.  RCA can be the first point of call for your patients after a rare cancer diagnosis . 

Complete the referral form below and one of RCA’s specialist cancer navigators will be in contact with your patient within one business day.

HCP Details

First name *

Last name *

Email *

Best phone number to contact you on?

Company / Organisation *

Job title *

Rare Cancers Australia requires consent from the patient to accept this referral. By ticking this box you are confirming consent has been obtained. *

Details of person being referred

Patient's First Name *

Patient's Last Name *

Gender Male Female Other

Date of Birth

Email *

Phone Number *

State

Postcode *

Is the person you are referring Aboriginal and/or Torres Strait Islander? Yes No Unknown

Preferred language at home (if not English)

Will an interpreter be required? Yes No

Preferred method of contact * Phone Call Phone Text Email

Type of Cancer *

Date of Diagnosis

Stage

Grade (If known)

If a medical confirmation of diagnosis is available please attach (a specialist letter, discharge summary, pathology report or genomic testing report)CancelMax file size: 10mb. File types allowed: pdf

Type of support the patient requires Information about their cancer Emotional support Peer support Practical and social support Financial support Clinical support Other

Additional information to assist this referral

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