Suspected Lid, Orbital & Conjunctival Cancer Referral Form referral date



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                  DOB:       NHS no:            

Suspected Lid, Orbital & Conjunctival Cancer Referral Form

REFERRAL DATE      

To make a referral, FAX this form within 24 hours of decision to refer.

You may also fax an accompanying letter if you wish to do so.


NOTE: For Choose & Book referrals please code as “2 week referral Head & Neck”
This form should NOT be used for suspected basal cell carcinomas which should be referred to the Eyelid Oncology Services at Moorfields Eye Hospital in the usual way.

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



Fax to: 020 7566 2073




Hospital

Phone

Fax

Email: select & copy OR +click



Moorfields

0207 566 2357

0207 566 2073






Royal London

0207 767 3333

0203 594 3278




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

USUAL GP NAME      

PRACTICE NAME:        PRACTICE CODE:       

PRACTICE ADDRESS:       




BYPASS:       

MAIN:        FAX:        EMAIL:       

REFERRING CLINICIAN:       



INSTRUCTIONS TO USERS

This form has THREE sections for specific tumours: one section each for orbital tumours, lid tumours 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.

— GO TO NEXT PAGE



CLINICAL DETAILS

SPECIFIC INFORMATION ABOUT THIS REFERRAL


ORBITAL TUMOUR

Site:



Left



Right

Duration:       months

Symptoms:



Vision loss/change



Diplopia



Proptosis/globe displacement

Investigations:



CT/MRI



Previous Biopsy? If so, diagnosis was:      




LID TUMOUR

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 Description (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.

— GO TO NEXT PAGE






CONJUNCTIVAL TUMOUR

Site:



Left



Right

Duration:       months

Symptoms:



Red Eye



Non-resolving conjunctivitis



Previous Biopsy? If so, diagnosis was:      


CONJUNCTIVAL TUMOUR Description (or mark diagram below):      
Diagram shows everted eyelids revealing conjunctival sac





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.

GENERAL INFORMATION ABOUT THIS REFERRAL

Any other relevant symptoms or signs not covered by the guidelines:      

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 on this link to view the leaflet



— GO TO NEXT PAGE



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


If there are any administrative issues with this form please contact:

Moorfields Eye Hospital NHS Foundation Trust, Moorfields Booking Centre: Either via CAB as electronic referral or faxed paper referral Booking Centre Tel: 020 7566 2357.

If you wish to discuss any clinical issues relating to this referral please contact:

Moorfields Eye Hospital NHS Foundation Trust, Secretary for the Lead Consultant for the Lid Oncology Service Tel: 020 7566 2010.
CLINICALLY-SPECIFIC AUTOMATIC TABULATED DATA
IMAGING STUDIES Please include date:       and location:      


     

     
ROUTINE AUTOMATIC TABULATED DATA
PAST MEDICAL HISTORY

     
ALLERGIES

     
MEDICATION

     
OFFICE USE ONLY


Suspected Lid, Orbital & Conjunctival Cancer Referral Form Page of

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






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