Suspected Head and Neck Cancer 2 Week Wait Referral



Download 33.26 Kb.
Date conversion31.01.2017
Size33.26 Kb.
G

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




Address






GP Code




Telephone Number




Fax Number




Postcode










Patient Name




Previous Surname




Date of Birth




Age




Sex (M/F)




NHS Number




Patient Tel No: Home




Has patient previously visited this hospital?




Mobile




Work




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?

Y

N

Immediate Referral: patients with tracheal compression including stridor due to thyroid swelling

Urgent Referral

Hoarseness > 3 weeks







Unexplained persistent sore throat




Stridor







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






Comments

(additional info)








Hospital Office Use Only

Date received:

Appointment date:

Malignant: Y/N

DH: 04/2007


The database is protected by copyright ©dentisty.org 2016
send message

    Main page