Breast screening: very high risk women surveillance protocols

The NHS breast surveillance protocols for women at very high risk of developing breast cancer.

Applies to England


Breast screening referral form for women at very high risk

This file may not be suitable for users of assistive technology.

Request an accessible format.
If you use assistive technology (such as a screen reader) and need a version of this document in a more accessible format, please email Please tell us what format you need. It will help us if you say what assistive technology you use.


Healthcare professionals working in the NHS Breast Screening Programme should use these protocols.

They apply to women referred to the screening programme with a very high risk of developing breast cancer.

Complete the referral form when referring a woman to breast screening because she has been clinically identified as being at higher risk of developing breast cancer. It can be completed electronically or printed out and completed manually.

Contact the screening helpdesk with any queries about this publication, making sure you include its full title.

Published 1 June 2013
Last updated 31 August 2022 + show all updates
  1. New version of the breast screening referral form for women at very high risk. Expanded information requirements in section B.

  2. Updated 'Breast screening referral form for women at very high risk' following an update in the breast screening IT system.

  3. Change to the referral form for women at very high risk. Added a section about a woman’s previous history of breast surgery.

  4. Update to section 3, to include treating clinician referral to very high risk screening for patients carrying a genetic mutation meeting the eligibility criteria.

  5. Edited sections 6.1 – process before MRI screening and 6.2 – review of background diversity in the protocols document.

  6. Added note to the referral form that BARD are excluded from needing to sign the declaration.

  7. Minor changes to all 3 documents including clarification that women already in the VHR programme can continue to be screened until their 71st birthday.

  8. Amended very high risk referral form.

  9. Reviewed, updated and reformatted guidance as HTML format.

  10. Added updated referral form.

  11. Updated high-risk referral form.

  12. Added breast screening referral form.

  13. First published.