Pan London Suspected Lid, Orbital, Retinoblastoma & Conjunctival Cancer Referral Form



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                  DOB:       NHS no:            

Pan London Suspected Lid, Orbital, Retinoblastoma & Conjunctival Cancer Referral Form

Press the key while you click here to view the Pan London Suspected Cancer Referral Support Guide





REFERRAL DATE      


Please email or send e-referral within 24 hours.

Fax is no longer supported due to patient safety and confidentiality risks.

Press the key while you click here to view the list of hospitals you can refer to





Copy the hospital details from the webpage and paste them onto the line below.

PATIENT DETAILS


SURNAME:        FIRST NAME:        TITLE:       

GENDER:        DOB:        AGE:        NHS NO:       

ETHNICITY:        LANGUAGE:       


INTERPRETER REQUIRED TRANSPORT REQUIRED


PATIENT ADDRESS:        POSTCODE:       


DAYTIME CONTACT:       

HOME:        MOBILE:        WORK:       

EMAIL:       


CARER/KEY WORKER DETAILS


NAME:        CONTACT:        RELATIONSHIP TO PATIENT:       
COGNITIVE, SENSORY OR MOBILITY IMPAIRMENT



COGNITIVE SENSORY MOBILITY DISABLED ACCESS REQUIRED

PLEASE INCLUDE RELEVANT DETAILS:       


SAFEGUARDING

SAFEGUARDING CONCERNS

PLEASE INCLUDE RELEVANT DETAILS:       
GP DETAILS

USUAL GP NAME:       

PRACTICE NAME:        PRACTICE CODE:       

PRACTICE ADDRESS:       




BYPASS:       

MAIN:        FAX:        EMAIL:       

REFERRING CLINICIAN:       



REASON FOR SUSPECTED CANCER REFERRAL

This form has FOUR sections for specific tumours: one section each for lid tumour, orbital tumour, retinoblastoma and conjunctival tumours. These are followed by ONE general information section.

You will (usually) only need to complete one specific tumour section. Check the box at the top left of

the relevant specific tumour section and fill in the clinical details. Scroll down to complete the GENERAL section. Please check the ROUTINE CLINICAL DATA inserted at the end of the form.

Press the key while you click here to view Pan London Suspected Lid, Orbital, Retinoblastoma & Conjunctival Cancer Referral Guide








LID TUMOUR

This form should NOT be used for suspected basal cell carcinomas. Please refer to the Eyelid Oncology Services at Moorfields Eye Hospital or use the Pan-London Suspected Skin Cancer Referral Form for suspected BCCs that are rapidly growing near the eyelid, nose or lip.

Site:      

Duration:       months

Size:       mm.



Malignant Melanoma

If suspected please check relevant boxes:






Growing in size



Changing shape



Changing colour






Inflamed



Ulceration / Bleeding



Palpable Lymph nodes



Squamous Cell Carcinoma/Other

If suspected please check relevant boxes:






Bleeding



Crusty/Not healing



Growing in size






Palpable lymph nodes



Immunosuppressed



Organ transplant



LID TUMOUR DIAGRAM Describe here:       or mark diagram below.


HOW TO MARK THE DIAGRAM

Place the mouse cursor over the diagram at the position of the lesion. Click the left mouse button. Use the keyboard to mark the diagram (X marks the lesion). Use the mouse or arrow keys to move left or right or to adjacent lines. Please do not press the key as it may cause alignment problems with your markers.







ORBITAL TUMOUR

Site:



Left



Right

Duration:       months

Symptoms:



Vision loss/change



Diplopia



Proptosis/globe displacement

Investigations:



CT/MRI



Previous Biopsy? If so, diagnosis was:      


RETINOBLASTOMA

Consider urgent referral (for an appointment within 2 weeks) for ophthalmological assessment for retinoblastoma in children with an absent red reflex.

Site:



Left



Right

Duration:       months




CONJUNCTIVAL TUMOUR

Site:



Left



Right

Duration:       months

Symptoms:



Red Eye



Non-resolving conjunctivitis



Previous Biopsy? If so, diagnosis was:      



CONJUNCTIVAL TUMOUR DIAGRAM Describe here:       or mark diagram below.


HOW TO MARK THE DIAGRAM

Place the mouse cursor over the diagram at the position of the lesion. Click the left mouse button. Use the keyboard to mark the diagram (X marks the lesion). Use the mouse or arrow keys to move left or right or to adjacent lines. Please do not press the key as it may cause alignment problems with your markers.



Diagram shows everted eyelids revealing conjunctival sac





GENERAL INFORMATION ABOUT THIS REFERRAL

Referral is due to CLINICAL CONCERNS that do not meet NICE/pan-London referral criteria (the GP MUST give full clinical details in the ‘additional clinical information’ box at time of referral)

Additional clinical information:      

Personal/relevant patient information:      

Past history of cancer:      

Relevant family history of cancer:      



I have discussed the possible diagnosis of cancer with the patient



The patient has been advised and confirmed they will be available for an appointment within the next two weeks



I have counselled the patient regarding the referral process and offered the pan-London information leaflet. Offering written patient information increases patient experience and reduces non-attendance. These are available in 11 different languages.

Press the key while you click here to view the leaflet








This patient has been added to the practice suspected cancer safety-netting system

Press the key while you click here to view Pan London Practice-based Suspected Cancer Safety Netting System










THIS SECTION IS FOR REFERRALS FROM SECONDARY CARE ONLY

If this is a confirmed cancer referral from secondary care, you MUST include the inter-provider transfer form.

If patient is on open cancer pathway please tick one:






31 day



62 day

Diagnosis:



Orbital Tumour



Lid Tumour



Conjunctival Tumour

Cancer is:



Probable



Possible



Definite


INVESTIGATIONS

Please ensure this referral includes ALL the relevant investigations including blood tests and imaging. If there are any pending test results that you have organised at the time of this referral please provide information including TYPE OF INVESTIGATION requested (bloods, imaging) and TRUST performing the tests in the box below.

      



CLINICALLY-SPECIFIC AUTOMATIC TABULATED DATA

IMAGING STUDIES (in past 3 months) Please include date:       and location:      

     
ROUTINE AUTOMATIC TABULATED DATA

MEDICAL HISTORY

     
ALLERGIES

     
MEDICATION

     

OFFICE USE ONLY

Pan London Suspected Lid, Orbital, Retinoblastoma & Conjunctival Cancer Referral Form Page of

(Version: Pan London changes MSW v1.0; 12/04/2016)






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