GYNAECOLOGICAL RAPID ACCESS PMB CLINIC

REFERRAL FORM

Completed forms should be faxed to the Women’s Unit 01723385065

then handed to patient

For completion by GP:
Patient Details:
(Please attach label)
Is this a 2WW Referral
Yes
No
Date of referral:
……………….. / Full Name: ……………………………………………………………………
Address: ……………………………………………………………………..
…………………………………………………………………………….……
Post Code ………………………..…. Tel: ………………………………
Date of Birth: ………………….……. GP: ………………………………
Hosp Unit No: ………………………. NHS No: ………………………….
Transport: None / Car 1 / Car 2 / Tail lift / Escort
(delete as appropriate)
Please tick as appropriate
(Box 1 and 2 and at least one other box must be ticked or the referral will be returned)
1. MY PATIENT IS NOT ON HRT AND HAS NOT
TAKEN ANY HRT FOR 2 MONTHS
2. Clinical Vaginal Assessment done
3. Post Menopausal Bleeding
(occurring 6 months or more after last menstrual period)
4. Consultant Referral

For completion in hospital clinic:

Brief Patient History Date of Visit / / .

Ultrasound

Endometrial thickness:
Comments:

Pipelle Sample Yes No Unobtainable

Cavity……..cm
Appointment for Gynaecology Clinic Yes No
Date ………………………………………………………………..

I:\2 week wait\REFERRAL FORMS\Scarb pmb gp referral proforma revised 0304.docJune 2014

Patient InformationYour doctor has arranged for you to attend the Rapid Assessment Post-Menopausal Bleeding Clinic.
Although in 90% of cases bleeding after the menopause has a simple explanation (or even no explanation at all), in a minority it can be a warning of disease of the lining of the womb (endometrium). Sometimes, this may even be cancer of the endometrium, but this condition, if detected at an early stage, can usually be simply treated by surgery with a good prospect of cure.
The purpose of the rapid assessment clinic is to avoid the waiting associated with ordinary clinic referrals so that those who do not require further investigation (the majority) can be quickly reassured and those who do can have it organised without further delay.
When you arrive at the clinic a nurse will ask you some general questions. Your doctor will already have supplied many of your clinical details.
You will then have an ultrasonic scan to measure the thickness of the lining of the womb. If the lining of the womb is of normal thickness you do not require further investigation because where there is disease of the womb lining it is always thicker than it should be. You will be returned to the care of your doctor with instructions on what to do if the problems persist.
If the lining of the womb appears thickened on the scan it does not automatically mean that you have cancer, it means you need further investigation.
This will begin in the rapid assessment clinic where you will be offered endometrial sampling. This is done in the clinic by a doctor or by a specially trained nurse. The sample will be sent to the pathology department and you will be given an appointment to be seen in the Gynaecology clinic the following week.
At your clinic visit, the results will be discussed with you as well as the need for any further investigation.
If you have any further questions or concerns, please ring the Sue Thompson Lead Nurse for Gynaecology on 01723 385290. /

GYNAECOLOGICAL

RAPID ACCESS CLINIC

Women’s Unit
Main Entrance
ScarboroughHospital
Woodlands Drive
Scarborough
North Yorkshire
YO12 6QL
The Women’s Unit Co-ordinator will ring you at home
to arrange your appointment.
Should you need to change it please ring
01723 385358
Time of appointment: ……………………………….
Date of appointment: ..………………………………
Please bring this form with you when you attend.

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