«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHSno:«PATIENT_Current_NHS_Number» «PRACTICE_Name»
Suspected Lung 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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 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
Note:If signs of Superior Vena Cava Obstruction or Stridor consider IMMEDIATE REFERRAL.
Please check one or more of the boxes below if this applies to the patientAbnormal CXR / History of COPD
Current Smoker / Ex-smoker
Persistent HAEMOPTYSIS in smoker or ex-smoker over 40 years of age
None / Once / More than once
Unexplained or persistent symptoms (>3weeks) of:
Cough / Wheeze / Weight Loss
Chest/shoulder pain / Breathlessness / Hoarseness
The following clinical signs:
Chest signs / Finger clubbing
Lymphadenopathy (cervical/supraclavicular) or features of metastasis from lung cancer
Any other relevant symptoms not covered by the guidelines:
Duration of symptoms:
Family History of cancer including age at diagnosis:
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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname» DOB:«PATIENT_Date_of_Birth» NHS no:«PATIENT_Current_NHS_Number» «PRACTICE_Name» Error! Reference source not found.
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
Please include the results of any relevant, available investigations with this form.
Depending on the clinical context you may wish to include:
FBC, ESR, CRP, U&Es, eGFR, LFTs, Bone ProfileSerum Calcium
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 Lung Cancer Referral FormPage 1 of 2
(Version: V1.1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein