Suspected Head and Neck Cancer 2 Week Wait Referral

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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 (Please do not delay in sending the referral, the letter can be sent at a later date) and fax immediately to the above number. The original cover sheet and letter should be retained by the referring practice. Please do not send the original copy to the booking centre as this may cause duplication.

Name of Referral Doctor

Date of Decision to Refer

GP Code

PCT Code

Registered GP


GP Code

Telephone Number

Fax Number


Patient Name

Previous Surname

Date of Birth


Sex (M/F)

NHS Number

Patient Tel No: Home

Has patient previously visited this hospital?



Hospital number (if known)

Special Requirements

Referral information

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

Urgent Referral

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:

A solitary nodule increasing in size

Unexplained hoarseness or voice changes

A history of neck irradiation

Very young (pre-pubertal) patient

A family history of an endocrine tumour

Patient aged 65 years and older


(additional info)

Hospital Office Use Only

Date received:

Appointment date:

Malignant: Y/N

DH: 04/2007

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