Suspected Head & Neck Cancer Referral Form



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Suspected Head & Neck Cancer Referral Form

Press the key while you click here to VIEW REFERRAL GUIDELINES

REFERRAL DATE:       




For Choose and Book referrals, attach this template to a referral in Choose and Book within 24 hours of creating the request - an appointment must be made for the patient before they leave the practice.

Press the key while you click here to VIEW LEAD CLINICIAN CONTACT INFORMATION

Please X the corresponding box for the hospital the referral is being made to and fax/send within 24 hours.






Hospital

Phone

Fax

Email: select & copy OR +click



Barnet

0208 370 9079

020 8375 1977

RF-tr.bcf2weekwaitreferrals@nhs.net



Barts & London

020 7767 3333

020 3594 3278






BHRUT

01708 435 065

01708 435 074/367






Chase Farm

0208 370 9079

020 8375 1977

RF-tr.bcf2weekwaitreferrals@nhs.net



Homerton

020 8510 5099

0020 8510 7832

     



Princess Alexandra

01279 827 550

01279 827 171

tpa-tr.FastTrackReferrals@nhs.net



UCLH

020 3447 9599

020 3447 9932

uclh.2ww@nhs.net



Whipps Cross

0208 539 5522 extensions 4348/4349/4350

0208 928 8836




 Patient has previously visited selected hospital HOSPITAL No:       

PATIENT DETAILS



SURNAME:        FIRST NAME:        TITLE:       

GENDER:        DOB:        NHS NO:       

ETHNICITY:        LANGUAGE:       



 INTERPRETER REQUIRED  TRANSPORT REQUIRED



PATIENT ADDRESS:        POSTCODE:       



DAYTIME CONTACT:       


HOME:        MOBILE:        WORK:       

EMAIL:       


GP DETAILS (IF REFERRAL IS FROM DENTIST PLEASE ASK PATIENT FOR GP DETAILS)

USUAL GP NAME:       

PRACTICE NAME:        PRACTICE CODE:       

PRACTICE ADDRESS:       





BYPASS:       

MAIN:        FAX:        EMAIL:       



DENTIST DETAILS (ONLY COMPLETE THIS SECTION IF REFERRAL IS FROM DENTIST)

DENTAL PRACTICE NAME:        DENTAL PRACTICE ADDRESS:       



TEL NO:        FAX NO:        EMAIL:       


THIS REFERRAL IS FROM:  GP  Dentist


REFERRING CLINICIAN:       

CLINICAL DETAILS

CANCER AREA SUSPECTED



Nose



Sinus



Pharynx



Oral Cavity



Salivary Gland



Lip



Larynx



Thyroid



Other (please specify):

     

RISK FACTORS



Poor Diet



Alcohol



Smoker



Occupation



History of Head and Neck Irradiation

SYMPTOMS/SIGNS

ENT



STRIDOR – Refer same day



Hoarseness – For more than 4 weeks with normal CXR. Do CXR before referral.



Sore throat – Persistent, no other cause



Otalgia – Persistent, no other cause, unilateral

NECK



Thyroid solitary nodule increasing in size



Lump in neck – Unresolved neck masses for more than 3 weeks



Parotid/Submandibular swelling – Unexplained, persistent

MOUTH



Oral Swellings – For more than 3 weeks



Ulceration of oral mucosa – For more than 3 weeks



Red/White patches on oral mucosa if pain or sudden bleeding



Tooth mobility – Unexplained, for more than 3 weeks

Any other relevant symptoms not covered by the guidelines:      

Duration of symptoms:      

Family History of cancer including age at diagnosis:      



I confirm that I have discussed the possibility with the patient that the diagnosis may be cancer



I confirm that I have explained the two week wait appointment process to the patient


Please hand the patient a copy of the URGENT REFERRALS PATIENT INFORMATION LEAFLET

Press the key while you click here to view the leaflet


CLINICALLY-SPECIFIC AUTOMATIC TABULATED DATA
TFTs

     


FBC

     



ESR

     


CRP

     


LFTs

     



U&Es

     




RELEVANT IMAGING STUDIES Please include date:       and location:      

     
ROUTINE AUTOMATIC TABULATED DATA

PAST MEDICAL HISTORY

     


ALLERGIES

     


MEDICATION

     


OFFICE USE ONLY



Suspected Head & Neck Cancer Referral Form Page of

(Version: MSW1.1; 17/06/2015)






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