Gp Referral Proforma for Suspected

2WW

GP REFERRAL PROFORMA FOR SUSPECTED UROLOGICAL CANCER

PLEASE ATTACH ELECTRONICALLY TO CHOOSE & BOOK REFERRAL
On completion please attach to Choose & Book Referral. Please contact the number below if CAB unavailable
Decision to refer date: UBRN:
Is patient aware that this is a suspected cancer referral? Yes No
If No, please state reasons why:
Has patient information leaflet been issued: Yes No
If No, please state reasons why:
Does the patient have availability within the next 14 days? Yes No
Please state any days which the patient is NOT available within the next two weeks:
Patient Details:
Surname: «PATIENT_Surname»
Forename: «PATIENT_Forename1»
Address: «PATIENT_House» «PATIENT_Road»
«PATIENT_Locality»
«PATIENT_Town»
«PATIENT_Postcode»
DOB: «PATIENT_Date_of_Birth»
Hosp No: «REFERRAL_Hospital_number»
NHS No: «PATIENT_New_Format_NHS_Number»
Contact Tel No: «PATIENT_Main_Comm_No» / Referring GP Details:
Name: «REFERRAL_Clinician»
Practice: «PRACTICE_Name»
«PRACTICE_House»
«PRACTICE_Road»
«PRACTICE_Locality»
«PRACTICE_Town»
«PRACTICE_County»
«PRACTICE_Postcode»
Telephone No: «PRACTICE_Main_Comm_No»
Fax No: 01275 891637
Prostate:
Hard, irregular prostate typical of a prostate carcinoma
with a normal prostate, but rising / rasied aged specific PSA, with or without LUTS (in patients compromised by other comorbidities, a discussion with the patient or carers and / or a specialist may be more appropriate)
with symptoms and high PSA levels
High PSA (> 20ng/ml) in men with clinically malignant prostate/and/or bone pain
Elevated age specific PSA in men with 10 year life expectancy
Please specify PSA result:
Date taken:
Age specific PSA ranges:
50 – 59 years >3.0ng/ml
60 – 69years >4.0ng/ml
70yrs and older >5.0ng/ml / Bladder and Renal:
Any age with painless macroscopic haematuria
40 years and older with recurrent or persistent urinary tract infection associated with haematuria
50 years and older with unexplained microscopic haematuria
Abdominal mass identified clinically or on imaging thought to arise from urinary tract
Testicular:
Swelling or mass in body of the testis / Penis:
Any suspected penile cancer

Past Medical History, Medication and Allergies will automatically be included in form. Please enter below any other significant additional information or attach relevant results/documentation to the UBRN in Choose & Book.

This form should only be used for patients who meet the NICE referral criteria for suspected cancer (2005). All other referring symptoms should be referred by letter.

Do not use this form for non-suspected cancer referrals

For completion by Trust and use for fax back acknowledgement to GP / Date received :
Date of 1st Appointment:
Patient informed by : Letter □ Telephone □
Patient Details:
Surname: «PATIENT_Surname»
Forename: «PATIENT_Forename1»
Hosp No: «REFERRAL_Hospital_number»
NHS No: «PATIENT_New_Format_NHS_Number»

Past Medical History:

«MEDICAL_HISTORY»

«PROBLEMS»

Medication:

«REPEATS»

Allergies:

«DRUG_ALLERGY»

Should the Choose and Book system become unavailable, please contact your local CaB Lead.
Bristol / 0117 9841602

Refer to:

UHB

NBT

Weston

Page 1 of 2 BNSSG Urology Referral Vision

Last saved on Wednesday, 07 April 2010