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SOUTH WEST LONDON CANCER NETWORK Lung Cancer Referral Form Rectal Examination

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					                       SOUTH WEST LONDON CANCER NETWORK                                   Suspected Urological Cancers Referral Form                                 (NICE 2006)

                                                                  Date of GP decision to refer:                                          No. of pages faxed:
               Urgent Referrals Criteria
                 (Please tick category)

                                                                                                                               GP DETAILS
UR 1 - Clinically malignant prostate on rectal examination
(PSA done at time of referral)
                                                             
                                                                  GP name and initials:                                                   GP Practice Code:
UR 2 - Asymptomatic men with raised or rising age
specific PSA
                                                             
                                                                  Address:                                                                Post Code:
UR 3 - Symptomatic patients with high PSA                    
UR 4 - Male or female patients of any age with painless
macroscopic haematuria.
                                                             
                                                                  Telephone No:                                                           Fax. No:
UR 5 Patients aged >40 with recurrent or persistent UTI          NB Patients referred under criterion UR 6 must have
associated with haematuria
                                                                  normal creatinine and no proteinuria
UR 6 Patients aged <50 with microscopic haematuria
AND no proteinuria and NORMAL serum creatinine.
                                                             
Creatinine ……………… mmol/l                                                                                                   PATIENT DETAILS
Proteinuria ………………
                                                                  Last Name:                                                             First Name:
UR 7 Patients aged >50 with unexplained microscopic          
haematuria should have an urgent referral                         Address:                                                               Post Code:
UR 8 Any patient presenting with symptoms or signs of        
penile cancer

UR 9 A suspicious testicular mass                            
UR10 A renal mass                                            
                                                                  Daytime Tel or Mobile:                                                 Gender:               M           F   
                                                                  Date of Birth:                                                         Age:
                                                                  Interpreter required?         Y/N                                      Language:                     Ethnicity:
                                                                  Hospital No:                                                           NHS No:
                                Patient Awareness Questions:

1. Has the patient been made aware of the nature of their referral? Yes  No 
2. Has the patient been supplied with supportive information                                      COMMENTS/OTHER REASONS FOR URGENT REFERRAL
about the Urgent Suspected Cancer referral process?                 Yes  No 
3. Have you asked the patient if they will be available
to attend an appointment within the next two weeks?                Yes  No 
4. Has the patient indicated to you that they
would be available to attend an appointment within the             Yes  No 
next two weeks?

                                                                                 NB Patients referred under criterion UR 6 must have normal creatinine and no proteinuria


                                                                                                                                                                                    June 2006
                     SOUTH WEST LONDON CANCER NETWORK
             How to make urgent referrals for suspected urological 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                               St Helier Hospital
            Dorking Road, Epsom                              Wrythe Lane, Carshalton
             Surrey KT18 7EG                                    Surrey SM5 1AA

FAX:                     020 8296 2741           FAX:                      020 8296 2741

TEL:                     020 8296 2742           TEL:                      020 8296 2742




         Mayday Healthcare NHS Trust                      St George’s Healthcare NHS Trust

        Mayday University Hospital                             St George’s Hospital
       London Road, Thornton Heath                           Blackshaw Road, Tooting
            Croydon CR7 7YE                                     London SW17 0QT


FAX:                        020 8401 3337        FAX:                         020 8725 0778

TEL:                        020 8401 3986        TEL:                         020 8725 1111

                                                 E-mail: cancerreferraloffice@stgeorges.nhs.uk


          Kingston Hospital NHS Trust                       Kingston Hospital NHS Trust

             Kingston Hospital                                Queen Mary’s Hospital
              Galsworthy Road                                  Roehampton Lane
             Kingston KT2 7QB                                  London SW15 5PN


FAX:                        020 8934 3306        FAX:                         020 8934 3306

TEL:                        020 8934 3305        TEL:                         020 8934 3305




                                                                                                      June 2006

				
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Description: SOUTH WEST LONDON CANCER NETWORK Lung Cancer Referral Form Rectal Examination