Urology Testicular Suspected Cancer Referral Form

Document Sample
Urology Testicular Suspected Cancer Referral Form Powered By Docstoc
					          North Central London & West Essex Cancer Commissioning Network
                               Suspected Urological Cancer Referral Form
To make a referral, FAX this form to the relevant Hospital. You may also fax an accompanying letter/ print out if you wish to do so.

DATE OF REFERRAL:
Please the corresponding box for the hospital the referral is being made to:

Barnet                             Chase Farm                       North Middlesex                   PAH
Fax: 020 8375 1977                 Fax: 020 8375 1977               Fax: 020 8887 2663/4              Fax: 01279 827 171
Tel: 020 8375 9079                 Tel: 020 8375 9079               Tel: 020 8887 2661/2              Tel: 01279 827 550
Royal Free                         UCLH                             Whittington
Fax: 020 7433 2950                 Fax: 020 3447 9932               Fax: 020 7288 5621
Tel: 020 7433 2969                 Tel: 020 3447 9599               Tel: 020 7288 5511/12

The PATIENT                                                         REFERRAL INFORMATION must be completed

SURNAME:                                                            Macroscopic Visible Haematuria without UTI                Y   N
                                                                    Persistent/Recurrent UTI, with haematuria >40 yrs         Y   N
FIRST NAME:

ADDRESS:                                                            Non Visible Microscopic Haematuria age >40                Y   N
                                                                    years (2 out of 3, 1+ or more not trace if no
                                                                    known cause)
                                                                    Swelling in the body of the Testis – suspicious           Y   N
DOB:                                               Male/Female      of cancer i.e. not varicaele/ epid cysts
TEL No:                                                             Has U/S been performed?                                   Y   N
WORK NO                                                             If yes provide date & state where
MOBILE NO:
NHS NO (required):                                                  Palpable renal masses or suspicious renal                 Y   N
                                                                    masses on radiological imaging
Has the patient previously visited the hospital?         Y/N        Date & type of imaging performed

HOSPITAL NO:
Is an interpreter required? If yes, which language?
                                                                    A high PSA in men with clinically malignant               Y N
Is transport required?                                   Y/N        prostate or bone pain, or unexplained urological
                                                                    symptoms.
                                                                    PSA Value & date of PSA test

Family History:                                                     Asymptomatic with age specific raised PSA in              Y N
                                                                    men with negative MSU .
Medical History:
                                                                    PSA value & date of PSA test
                                                                    If PSA borderline, repeat in 1-3 months
Medication:
                                                                    If PSA rising, refer


The REFERRING GP:                                                   Suspected penile cancer                                   Y N
NAME:
ADDRESS:                                                            State any relevant findings examination

                                                                    Information given to Patient
TEL NO:
FAX NO:

GP SIGNATURE:




                                                                                                                     3.8.10

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:9
posted:12/21/2011
language:
pages:1