SOUTH WEST LONDON CANCER NETWORK Lung Cancer Referral Form

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					SOUTH WEST LONDON CANCER NETWORK

Suspected Gynaecological Cancers Referral Form (NICE 2006)
No. of pages faxed:

Date of GP decision to refer:

Urgent Referrals Criteria (Please tick category)
GY 1 Lesions suspicious of cancer on cervix or vagina on speculum examination GP name and initials: Address:

GP DETAILS GP Practice Code: Post Code:

GY 2 Lesions suspicious of cancer on clinical examination of the vulva

Telephone No:

Fax. No:

GY 3 Palpable abdominal or pelvic mass (not obviously fibroids) Last Name: Address: GY 5 Post menopausal bleeding in a woman not on HRT Daytime Tel or Mobile: Date of Birth: Interpreter required? GY 7 Post menopausal bleeding in a women taking Tamoxifen Hospital No: Y/N

PATIENT DETAILS First Name: Post Code:

GY 4 Suspicious pelvic mass on ultrasound

GY 6 Persistent or unexplained post menopausal bleeding in a woman on HRT, after cessation of the HRT for 6 weeks

Gender: Age: Language: NHS No:

M

F

Ethnicity:

GY 8 Persistent intermenstrual bleeding and a negative pelvic examination

COMMENTS/OTHER REASONS FOR URGENT REFERRAL

April 2006

SOUTH WEST LONDON CANCER NETWORK How to make urgent referrals for suspected gynaecological cancers
Please FAX this form to the Cancer Office at the relevant hospital, with or without an accompanying letter. You should receive acknowledgement by fax that your referral has been received. Please ensure that the referral reaches the hospital within 24 hours of the GP’s decision to refer.
Epsom and St Helier NHS Trust Epsom and St Helier NHS Trust

Epsom General Hospital Dorking Road, Epsom Surrey KT18 7EG FAX: TEL: 01372 735402 01372 735345 FAX: TEL:

St Helier Hospital Wrythe Lane, Carshalton Surrey SM5 1AA 01372 735402 01372 735345

Mayday Healthcare NHS Trust

St George’s Healthcare NHS Trust

Mayday University Hospital London Road, Thornton Heath Croydon CR7 7YE

St George’s Hospital Blackshaw Road, Tooting London SW17 0QT

FAX: TEL:

020 8401 3337 020 8401 3986

FAX: TEL:

020 8725 0778 020 8725 1111

E-mail: cancerreferraloffice@stgeorges.nhs.uk

Kingston Hospital NHS Trust

Kingston Hospital NHS Trust

Kingston Hospital Galsworthy Road Kingston KT2 7QB

Queen Mary’s Hospital Roehampton Lane London SW15 5PN

FAX: TEL:

020 8934 3306 020 8934 3305

FAX: TEL:

020 8934 3306 020 8934 3305

April 2006


				
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Description: SOUTH WEST LONDON CANCER NETWORK Lung Cancer Referral Form