Rapid Access Prostate Clinic Referral Form

RAPC Referral Form

Submit Referral to:*
Patient Details*
First Name
Last Name
DOB*
MM
/
DD
/
YYYY
Address*
Telephone Number
General Practitioner Details*
General Pactitioner Name
First Name
Last Name
GP Practice Address
GP Practice Tel No*
Investigations: Prostate Specific Antigen (PSA) Test (Mandatory)Please wait six weeks to do a PSA test if a patient has an active urinary infection Prostate biopsy, TURP, or prostatitis. In a man with a normal DRE, repeat an abnormal PSA test at 6 weeks before referral.
- PSA Level 1*
- Date*
- PSA Level 2
- Date
- PSA Level 3
- Date
- Digital Rectal Examination
  (Strongly Recommended)
  All men with an abnormal Digital Rectal Examination (DRE) should be referred regardless of PSA
  DRE-Prostate feels benign
  DRE-Prostate feels suspicious
- Suspicious Lobe
- Anticoagulants/Antiplatelets
- Plavix
  Pradaxa
  Aspirin
  Warfarin
  Other
- Previous Prostate Biopsy
- Urinalysis

Follow us:

Advanced Medicine Exceptional Care

© 2017 Bon Secours Health System

Map of Ireland with Hospital locations

scroll top

Visited Pages

Appointment Request