«Title» «Forename» «Surname» DOB:«Date_of_birth» NHSno:«NHS_number» «Sender_organisation_name»
Suspected Colorectal Cancer Referral Form
Press the <Ctrl> key while you click on this link to VIEW REFERRAL GUIDELINES
REFERRALDATE:«Todays_date»
For Choose and Book referrals, attach this template to a referral in Choose and Book within 24 hours of creating the request - an appointment must be made for the patient before they leave the practice.
Press the <Ctrl> key while you click on this link to VIEW LEAD CLINICIAN CONTACT INFORMATION
Please X the corresponding box for the hospital the referral is being made to and fax/send within 24 hours.
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«Title» «Forename» «Surname» DOB:«Date_of_birth» NHSno:«NHS_number» «Sender_organisation_name»
Hospital / Phone / Fax / Email: select & copy to email clientBarnet / 0208 370 9079 / 020 8375 1977 /
Barts & London / 020 7767 3333 / 020 3594 3278
BHRUT / 01708 435 065 / 01708 435 074/367
Chase Farm / 0208 370 9079 / 020 8375 1977 /
Homerton / 020 8510 5099 / 0020 8510 7832
Newham / 020 7363 8817 / 020 7363 8818
North Middlesex / 020 8887 2661/2662/3390 / 020 8887 2663 /
Princess Alexandra / 01279 827 550 / 01279 827 171 /
Royal Free / 020 7433 2973/4 / 020 7433 2950/1
UCLH / 020 3447 9599 / 020 3447 9932 /
Whipps Cross / 0208 539 5522 extensions 4348/4349/4350 / 0208 928 8836
Whittington / 020 7288 3736/3542 / 020 7288 5621 /
Patient has previously visited selected hospital HOSPITALNo:
PATIENT DETAILS
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«Title» «Forename» «Surname» DOB:«Date_of_birth» NHSno:«NHS_number» «Sender_organisation_name»
SURNAME:«Surname» FIRSTNAME:«Forename» TITLE:«Title»
GENDER:«Gender» DOB:«Date_of_birth» NHSNO:«NHS_number»
ETHNICITY:«Ethnicity» LANGUAGE:«Main_spoken_language»
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«Title» «Forename» «Surname» DOB:«Date_of_birth» NHSno:«NHS_number» «Sender_organisation_name»
INTERPRETER REQUIRED TRANSPORT REQUIRED
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«Title» «Forename» «Surname» DOB:«Date_of_birth» NHSno:«NHS_number» «Sender_organisation_name»
PATIENTADDRESS:«Patient_address__single_line»
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«Title» «Forename» «Surname» DOB:«Date_of_birth» NHSno:«NHS_number» «Sender_organisation_name»
DAYTIMECONTACT':
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«Title» «Forename» «Surname» DOB:«Date_of_birth» NHSno:«NHS_number» «Sender_organisation_name»
HOME':«Patient_home_telephone_number» MOBILE':«Patient_mobile_telephone_number» WORK':«Patient_alternate_telephone_number»
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«Title» «Forename» «Surname» DOB:«Date_of_birth» NHSno:«NHS_number» «Sender_organisation_name»
EMAIL:
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«Title» «Forename» «Surname» DOB:«Date_of_birth» NHSno:«NHS_number» «Sender_organisation_name»
GP DETAILS
USUALGPNAME:«Usual_doctor»
PRACTICENAME:«Sender_organisation_name» PRACTICE CODE:«Registered_GP_practice_ID»
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«Title» «Forename» «Surname» DOB:«Date_of_birth» NHSno:«NHS_number» «Sender_organisation_name»
PRACTICEADDRESS:«Sender_address_building», «Sender_address_road», «Sender_address_locality», «Sender_address_post_town», «Sender_address_county», «Sender_post_code»
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«Title» «Forename» «Surname» DOB:«Date_of_birth» NHSno:«NHS_number» «Sender_organisation_name»
BYPASS':
MAIN':«Registered_GP_phone_number» FAX:«Registered_GP_fax_number» EMAIL:
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«Title» «Forename» «Surname» DOB:«Date_of_birth» NHSno:«NHS_number» «Sender_organisation_name»
REFERRINGCLINICIAN:«Sender_name»
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«Title» «Forename» «Surname» DOB:«Date_of_birth» NHSno:«NHS_number» «Sender_organisation_name»
CLINICAL DETAILS
REASON FOR REFERALRectal bleeding and looser stool and/or increased frequency of ≥ 3 weeks duration (age 40 and over)
Rectal bleeding without change in bowel habit with no obvious cause ≥ 3 weeks duration (age 50 years and over)
Change of bowel habit (tendency to looser stools) persisting for 3 weeks or more without bleeding (age 50 years and over)
Abdominal mass thought to be large bowel cancer (any age)
Palpable rectal mass (any age)
Males of any age with Hb ≤ 11g/100ml; Ferritin ≤30 mg/dL; MCV ≤ 79 iron deficiency picture
Non menstruating female with Hb ≤ 10g/100ml; Ferritin ≤30 mg/dL; MCV ≤ 79 iron deficiency picture
RECTAL EXAMINATION - preferred for 2 week wait referrals with rectal symptoms
Rectal examination findings:
If rectal exam not performed please state reason:
IS THE PATIENT CURRENTLY FIT FOR ENDOSCOPY? YES NO
Comments regarding fitness:
Any other relevant symptoms or signs not covered by the guidelines:
Duration of symptoms:
Family history of cancer including age at diagnosis:
I confirm that I have discussed the possibility with the patient that the diagnosis may be cancerI confirm that I have explained the two week wait appointment process to the patient
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«Title» «Forename» «Surname» DOB:«Date_of_birth» NHSno:«NHS_number» «Sender_organisation_name»
Please hand the patient a copy of the URGENT REFERRALS PATIENT INFORMATION LEAFLET:
Press the <Ctrl> key while you click on this link to view the leaflet
This form displays all recent pathology results. However, laboratory departments may code some results in a way which might not be picked up by this form. So please review them, add any you feel are relevant and delete any which are not.
Depending on the clinical context you may wish to include:
Hb, Ferritin, MCV, U&Es, eGFR, LFTs
CLINICALLY-SPECIFIC AUTOMATIC TABULATED DATA
ROUTINE AUTOMATIC TABULATED DATA
RECENT PATHOLOGY RESULTS
«Recent_Pathology»
PROBLEMS
«Summary»
ALLERGIES
«Allergies»
MEDICATION
«Current_Repeat_Templates»
OFFICE USE ONLY
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