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HPB Malignancy Referral Form

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Upper GI and hepatobilliary surgery

HPB Malignancy Referral Form

Please complete this form if you wish to make a HPB referral

Name:

Date of birth:

Phone number:

Email Address:

Referring Consultant:

Referring Hospital:

Is there imaging available on NIMIS?

Yes

No

Is there histology available?

Yes

No

Please indicate primary or secondary maligancy?

Primary

Secondary

Please provide clinical information for your referral

Contact Person Details:

Referring Doctor / CNS

Contact us

Mr McEntee secretary

F:01 803 2694

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Location:
Department of Hepatobiliary Surgery
Clinic 5, Whitty Wing, Level 1

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Mater Misericordiae University Hospital,
Eccles St, Dublin 7.

Ph: 353 (01) 803 2000

VAT No: IE6371402U
Registered in Ireland No: 351402
Charity No: CHY203
Registered Charity Number (RCN): 20000349

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