Urgent suspected head and neck cancer referal form



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URGENT SUSPECTED HEAD and NECK CANCER REFERAL FORM


PLEASE ENSURE THAT THIS FORM IS ATTACHED TO YOUR CHOOSE AND BOOK REFERRAL

Consultant/Hospital to which patient is being referred:





Patient details

GP / GDP Details (please circle)


NHS No




Dr:

Surname:




Address:

First Name:




Age / D.O.B:




Tel:

Fax:

Address:

Postcode:

Email:

Date of decision to refer:

Tel day:

Tel evening/mobile:


Signature:

Details of Patient’s GP (for General Dental Practitioner Referrals):

Dr:


Address:
Tel:

Have you told the patient that you suspect Head and Neck cancer? Y / N

Have you given the patient the 2WW information leaflet Y / N

Have you told the patient they will be seen within 2 weeks? Y / N

Has the patient had a previous diagnosis of cancer? Y / N (Specify if known)

Has the patient previously visited this hospital? Y / N

Hospital number (if known):



First language:

Interpreter required? Y / N



Symptoms and Clinical Findings
For suspected thyroid cancer, please use specific Thyroid 2ww form


CANCER AREA SUSPECTED (please tick as appropriate)

Oral Cavity  Larynx  Pharynx  Salivary Gland 

Sinus  Lip  Nose 

RISK FACTORS

Smoker  Ex-smoker  Chews Tobacco / Paan / Betel  * Alcohol units consumed per week _____________



Lump in neck > 3 weeks 

Hoarseness (refer smokers immediately, otherwise refer if for more than 4 weeks with normal CXR) 

Otalgia / sore throat (> 3 weeks, no other cause) 

Ulcer/mass in oral cavity (no other cause) 

Dysphagia 

Red and/or white patches on oral mucosa (especially if plus Pain, Bleeding, Swelling) 

Unexplained tooth mobility > 3 weeks 

STRIDOR – Refer immediately

P.T.O.


Additional Clinical Information: Include any investigations arranged or results obtained, and any other information you think relevant



* Alcohol units per drink:

The NHS recommends men should not regularly drink more than 3-4 units a day and women should not regularly drink more than 2-3 units a day. 'Regularly' in this context means drinking at this sort of level every day or most days of the week. Please refer to http://www.nhs.uk/tools/pages/nhsalcoholtracker.aspx to calculate number of units in various alcoholic drinks.







North West London

Hospitals NHS Trust
Fax: 020 8235 4188

Tel: 020 8235 4293



Ealing Hospital NHS Trust
Fax: 020 8967 5005

Tel: 020 8967 5000, x 3921



Imperial College Healthcare NHS Trust
Fax:    020 3312 1580

Tel:     020 3312 1527



Hillingdon Hospital NHS Trust
2WW fax line : 01895 279807
(Maxillofacial)

Alternante Fax: 01895 279538

Tel: 01895 279256
(ENT)

Alternante Fax: 01895 279408

Tel: 01895 279715


West Middlesex University Hospital NHS Trust
Fax: 020 8321 5157

Tel: 020 8321 6776




The Royal Marsden NHS Foundation Trust
Fax: 020 8661 3149

Tel:  0800 731 2325

Emailrmh-tr.referrals@nhs.net


Notes for patient use


You may like to write down here any questions that you may want to ask when you attend your appointment at the hospital

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You can get more information about the “two week”

appointment system from NHS Direct on 0845 46 47

You can also visit:


www.nhsdirect.nhs.uk

Why have I been

Referred to hospital under the

“2 – week wait”

appointment system?

Information for patients

Please make every effort to attend your appointment.

Your General Practitioner (GP) or Dentist has asked for you to

have a hospital appointment within two weeks. The “two week”

appointment system was introduced so that a specialist would see any patient with symptoms that might indicate cancer as quickly as possible.


Does this mean I have cancer?
No, it doesn’t. More than 70% of patients referred under the

“two week” appointment system do not have cancer, but a

simple condition.
So why has my GP referred me?
GPs diagnose and treat many illnesses themselves. However, on occasion they need to arrange for you to see a specialist hospital doctor. This could be for a number of reasons, such as:


  • The treatment already prescribed has not been effective.

  • Your symptoms need further investigation.

  • Investigations your GP arranged have shown some

abnormal results.
What symptoms might need an urgent referral?
Symptoms such as:


  • A lump that does not go away.

  • A change in the size, shape or colour of a mole.

  • Abnormal bleeding

  • A change in bowel or bladder habits

  • Continuous tiredness and / or unexplained weight loss.

There are national referral guidelines for your GP to use to make

a decision about whether it is appropriate to refer you for an appointment within two weeks.

What do I need to do now?


  • Make sure that your GP has your correct address and

telephone number, including mobile number.


  • Your GP or a member of practice staff will have made your appointment using Choose and Book and given you the confirmation.




  • You must let the hospital know immediately if you are unable to attend your appointment so that it can be rearranged or offered to someone else.


It is important that you arrange another date and time

if you cancel your appointment.
At the hospital


be given to you.


  • Please feel free to bring someone with you to this

appointment – do not feel that you have to be alone.




It is important to remember that even though

you are getting an urgent referral, being

referred to a specialist does not necessarily

mean that you have cancer.


Please ensure this form is received in the Trust within 24 hours of GP or Dental decision to refer

Latest version of the form is available at www.nwlcn.nhs.uk



Version 3.7


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