Fax: 020 8375 1977
Tel: 020 8370 9079 / Chase Farm
Fax: 020 8375 1977
Tel: 020 8370 9079 / BHRUT
Fax:01708 435 074/ 01708 435 367
Tel: 01708 435 065 / Barts & London
Fax: 020 3594 3278
Tel: 020 7767 3333
Homerton
Fax: 020 8510 7832
Tel: 020 8510 5099 / North Middlesex
Fax: 0208 887 2663/4
Tel: 0208 887 2662 / Newham
Fax: 020 7363 8818
Tel: 020 7363 8817 / Princess Alexandra
Fax: 01279 827 171
Tel: 01279 827 550
Royal Free
Fax: 020 7433 2950
Tel: 020 7443 9757 / UCLH
Fax: 020 3447 9932
Tel: 020 3447 9599 / Whipps Cross
Fax: 020 8928 8836Tel: 020 8535 6856 / Whittington
Fax: 020 7288 5621/3793
Tel: 020 7288 3070
PATIENT DETAILS (Please complete in block capitals) / GP DETAILS(Please complete in block capitals)
Forename: Surname:
Address:
Post code:
Date of Birth://
Sex: M F
NHS Number:
Has the patient previously visited the hospital?
Y N
Hospital Number:
Interpreter required: Y N Language: / Date referral sent:
Name of referrer:
Address:
Post code:
Phone number:
Fax number:
IMPORTANT: To be able to contact the patient within 48 hours of referral (day and evening), please provide patients preferred contact phone details / Home:
Daytime:
REFERRAL INFORMATION (Must be completed)
Macroscopic Visible Haematuria without UTI
Persistent/Recurrent UTI, with Haematuria >40 years
Unexplained Non Visible Microscopic Haematuria age >40 years (1+ dips or more not trace)
Palpable renal masses or suspicious renal masses on radiological imaging
Date & type of imaging performed:
Swelling in the body of the Testis – suspicious of cancer i.e. not varicocele/epid cysts
Previously Undescended Testicle
Has U/S been performed?
If yes, provide date and state where:
A high PSA in men with clinically malignant prostate or bone pain, or unexplained urological symptoms.
PSA Values & date of PSA tests:
Asymptomatic with age specific raised PSA in men with negative MSU
PSA value & date of PSA test:
If PSA borderline, repeat in 1-3 months
If PSA rising, refer
Suspected Penile Cancer
U and E Blood Test (Date and Result):
Family History of cancer including age of their diagnosis:
Any other relevant symptoms not covered by the guidelines:
I confirm that I have discussed the possibility with the patient that the diagnosis may be cancer
PLEASE INCLUDE WITH THIS PROFORMA PAST MEDICAL HISTORY, MEDICATIONS AND RESULTS AND YOUR REFERRAL LETTER IF APPROPRIATE
If you wish to discuss any clinical issues regarding the two week wait referral please contact:
Barnet and Chase Farm Hospital / Tel: 020 8216 4795Barking, Havering and Redbridge University Hospitals NHS Trust / Cancer Referrals Office
Tel: 01708 435065
Barts and the London Hospital / Urology Clinical Nurse Specialist/MDT Coordinator
Tel via switchboard: 02034165000 ex158565
Homerton University Hospital NHS Foundation Trust / Ms Jhumur Pati, Consultant Urological Surgeon
Tel:020 8510 7522
Mr Vinod Nargund, Consultant Urological Surgeon
Tel:020 8510 7522
NewhamUniversityHospital / Mr Frank Chinegwundoh;Consultant Urologist
Tel:020 7363 8227
Mr Turk; Consultant Urologist
Tel:020 7363 8227
PrincessAlexandraHospital NHS Trust / Fast Track Office
Tel:01279 827 550
Royal Free London NHS Foundation Trust / David Cullen, CNS
Tel: 020 77940500 ext. 38059
Urology Consultant of the Week via MDT Co-ordinators:
Tel: 020 7794 0500 ext 36759 or bleep 2379
UniversityCollegeLondon NHS Foundation Trust / Prof John Kelly, Prof Mark Emberton and Mr Suks Minhas (penile cancer) via Simon EvansUrology MDT Coordinator
Tel: 020 3447 7427
WhippsCrossUniversityHospital / Mr Prasad PatkiandMiss Jhumur Pati
Tel: 0203 5942664
The WhittingtonHospital NHS Trust / Mr Maneesh Ghei
Lead Cancer Clinician
(Via Secretary)Janice Bruce:
Tel: 020 7288 5223.
CNS
Tel: 020 7288 5252 ext. 5772
London Cancer 2wwUrology referral form
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