ST. LUKE’S CANCER ALLIANCE

LOWER GI – Suspected Cancer TWR referral form
Please fax this form back within 24 hours of seeing the patient for hospital appointment within 14 days

PATIENT’S DETAILS
Surname
First name(s)
Address
Date of birth
Home telephone:
Mobile/Work telephone:
NHS number:
Hospital number: / GP’s DETAILS
GP’s name
Surgery name
Surgery address
Surgery telephone:
Surgery fax:
URGENT TWR REFERRAL CRITERIA
ANY AGE / TICK / OVER 60 YEARS OF AGE / TICK
Rectal bleeding WITH change in bowel habit to looser stools and/or increased frequency of defecation PERSISTENT for 6 WEEKS / Rectal bleeding persistently WITHOUT anal symptoms (anal symptoms include: soreness, discomfort, itching, lumps and prolapse, as well as pain)
CONFIRMED iron deficiency anaemia WITHOUT obvious cause.
Criteria for iron deficiency requiring investigation:
o  Hb Male < 13.5 Female < 11.0
o  Ferritin < 15 / Change in bowel habit to looser stools and/or increased frequency of defecation, WITHOUT rectal bleeding and PERSISTENT for 6 WEEKS
Definite palpable right-sided abdominal mass / Why would this patient NOT be suitable for a ‘straight to test’ colonoscopy?
Definite palpable right-sided rectal mass
Please indicate if the patient has any of the following:
Insulin dependent diabetes / Warfarin
Non-insulin dependent diabetes / Clopiodgrel
Prosthetic valve / DVT/PE within 3/12
Previous endocarditis / AF with systemic embolous OR mitral stenosis
RENAL FUNCTION – PLEASE ENSURE THAT ONE OF THE TWO BOXES IS COMPLETED
PLEASE NOTE THAT THE REFERRAL WILL NOT BE ACCEPTED WITHOUT THIS INFORMATION
eGFR in the last 2 months ______mL/min
Date: / If no eGFR within last 2 months, please arrange bloods to be taken prior to referral.
Date of blood test:
ADDITIONAL MANDATORY CLINICAL INFORMATION REQUIRED:
Attach summary of past medical history, medication and allergies / TICK
Summary of past medical history, medication and allergies attached?
I have told this patient I am referring them under the TWR and have explained this process
Referral letter attached?
Referral date: GP signature
To Make a Referral FAX form to relevant Trust / FAX Number
Ashford Hospital / 0800 923 4668
Frimley Park Hospital / 01276 604506
Royal Surrey County Hospital / 01483 464848
St Peter’s Hospital / 0800 923 4668
Surrey & Sussex Healthcare Trust / 01737 231733