Suspected Head and Neck Cancer 2 Week Wait Referral
Date conversion 31.01.2017 Size 33.26 Kb.
loucestershire Hospitals NHS Foundation Trust: Fax 08454 222564
Suspected Head and Neck Cancer 2 Week Wait Referral Please use this form for all suspected head and neck (incl. thyroid) cancer referrals, attaching an accompanying letter where appropriate ( , the letter can be sent at a later date) and Please do not delay in sending the referral to the above number. The original cover sheet and letter should be retained by the referring practice. fax immediately
Please do not send the original copy to the booking centre as this may cause duplication.
of Referral Doctor
Date of Decision to Refer
Date of Birth
Patient Tel No: Home
Has patient previously visited this hospital?
Hospital number (if known)
Cancer area suspected: Oral cavity Larynx Pharynx Thyroid Neck lump
Referred to: ENT Maxillofacial
Have you told the patient the reason for referral?
Immediate Referral: patients with tracheal compression including stridor due to thyroid swelling
Hoarseness > 3 weeks
Unexplained persistent sore throat
Progressive mouth, throat ulceration
Swelling in parotid / submandibular gland
Persistent oral swelling/ulceration (>3 weeks)
Persistent red & white patches of the oral mucosa (painful/swollen/bleeding)
Unilateral, unexplained pain in head and neck > 4 weeks, associated with Otalgia and normal otoscopy
Unexplained tooth mobility > 3 weeks
Thyroid: a thyroid swelling associated with any of the following:
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