«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
Suspected Gynaecological Cancer Referral Form
Press the <Ctrl> key while you click on this link to VIEW REFERRAL GUIDELINES
REFERRALDATE:«SYSTEM_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.
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_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
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
SURNAME:«PATIENT_Surname» FIRSTNAME:«PATIENT_Forename1» TITLE:«PATIENT_Title»
GENDER:«PATIENT_Sex» DOB:«PATIENT_Date_of_Birth» NHSNO:«PATIENT_Current_NHS_Number»
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
ETHNICITY: LANGUAGE:
INTERPRETER REQUIREDTRANSPORT REQUIRED
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
PATIENTADDRESS:«PATIENT_House»«PATIENT_Road», «PATIENT_Locality», «PATIENT_Town», «PATIENT_County», «PATIENT_Postcode»
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
DAYTIMECONTACT:
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
HOME:«PATIENT_Main_Comm_No» MOBILE:«PATIENT_Mobile_No» WORK:«PATIENT_Alt_Comm_No»
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
EMAIL:
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
GP DETAILS
USUALGPNAME:«PATIENT_Usual_GP»
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
PRACTICENAME:«PRACTICE_Name» PRACTICE CODE:
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
PRACTICEADDRESS:«PRACTICE_House»«PRACTICE_Road», «PRACTICE_Locality», «PRACTICE_Town», «PRACTICE_County»,«PRACTICE_Postcode»
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
BYPASS:
MAIN:«PRACTICE_Main_Comm_No» FAX:«PRACTICE_Fax_No» EMAIL:
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
REFERRINGCLINICIAN:«REFERRAL_Clinician»
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
CLINICAL DETAILS
REASON FOR REFERALLesion suspicious of cancer on cervix or vagina on speculum examination or smear suggesting cancer urgently refer to colposcopy rather than via 2WW
Lesions suspicious of cancer on clinical examination of vulva or vagina
Ascites/pelvic mass on examination/ultrasound (not obviously fibroids/urological/GI)
Raised CA 125 and strong clinical suspicion of ovarian cancer (with USS if available)
Persistent intermenstrual bleeding (IMB) in women over 45 years of age with normal vaginal examination (lasting more than 6 weeks after stopping HRT/COCP if taken)
Postmenopausal Bleeding
HRT:Unexpected or prolonged bleeding for more than 6 weeks after stopping HRT
Any other relevant symptoms or signs not covered by the guidelines:
Duration of symptoms:
Family history of cancer including age at diagnosis:
Information given to patient:
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
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_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
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
Please include the results of any relevant, available investigations with this form.
Depending on the clinical context you may wish to include:
IMAGING STUDIES (Please include date and location)
CLINICALLY-SPECIFIC AUTOMATIC TABULATED DATA
ROUTINE AUTOMATIC TABULATED DATA
PAST MEDICAL HISTORY
«MEDICAL_HISTORY»
PROBLEMS
«PROBLEMS»
ALLERGIES
«DRUG_ALLERGY»
MEDICATION
«REPEATS»
Suspected Gynaecological Cancer Referral FormPage 1 of 2
(Version: V1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein