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At St. James’s Hospitals

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SABR (Lung) Referral Form
Patient Demographics
Patient Name
Patient Address
Date of Birth
Diagnosis / MRN
Referring Hospital / Referring Consultant
Insurance / Public Private / Insurance Details
Treatment Details
Treatment Site / Laterality / Lobe
Previous Radiotherapy Treatment Details
Previous RT / Yes No / Site / Dose
Details Included / Yes No N/A / Centre
Information Required for SABR Referral
Histology
Pathology/ Cytology report / choose oneIncludedNot AvailableUnable to Biopsy (give reason) / Reason:
Correspondence
Referral letters/ correspondence / documents / choose oneIncludedNot Available
Lung MDT report/ pro-format / choose oneIncludedNot AvailableNo MDT review completed / Comment:
Correspondence from surgical review / choose oneIncludedNot AvailableNot seen by Cardiothoracic Surgeon (give reason) / Reason:
Work-Up
PFTs Report - within 6 months of referral / choose oneIncludedIncluded but not recent (give reason)Unable to complete PFTs (give reason)Not Available (give reason) / Reason:
Date if not within 6 months:
EBUS Report (if completed) / choose oneIncludedNot Available (give reason) / Reason:
Recent Blood Results / choose oneIncludedNot Available (give reason) / Reason:
Imaging– must be dated within 12 weeks of referral
FDG Avid Lesions
PET Scan (whole body) report / choose oneIncludedAvailable on EPR (SJH)Not PET avid (scan > 12 weeks from referral)Not Available (give reason) / Reason:
PET Scan (whole body) images / choose oneAvailable on EPR (SJH)Disc sentAvailable on NIMISNot PET avid (scan > 12 weeks from referral)Not Available (give reason) / Reason:
FDG Non Avid Lesions
CT TAP report / choose oneIncludedAvailable on EPR (SJH)Not Available (give reason) / Reason:
CT TAP images / choose oneAvailable on EPR (SJH)Disc sentAvailable on NIMISNot Available (give reason) / Reason:
Medical History / Details
Co-morbidities/ Special Requirements
General Comments

Send completed referral form and associated reports/ documents to

Receipt of referral will be acknowledged in writing. Referrals will only be processed once all relevant requested information is received.

Send CT & PET images (discs) to MDT Coordinator, St Luke’s Radiation Oncology Centre, St James’ Hospital, James’ St., Dublin 8. Please ensure they are labelled with patient name, date of birth and MRN.

PPPG code / Version no. / Issue date / Review date / Developed by / Approved by
RT SJC F 208 / 00 / 6th March 2017 / March 2019 / Laoise Ryan / Dr Pierre Thirion & Dr Nazmy ElBeltagi
Associated Procedure: RT SJC P 034 SABR Procedure for Lung Tumours