Head and Neck- Two Week Wait Cancer Proforma
For General Dental Practitioners
Fax Number: (023) 92 681701 /
PATIENT DETAILS / REFERRING GDP PRACTICE DETAILS
NHS No / Referring DENTIST
Previous Surname / Practice Name
Forename / Practice Code
Address / Practice Address
Post Code / Practice Post Code
Daytime Phone Number / Practice Phone No
Evening Phone Number / Practice Fax No
Mobile Phone Number
URGENT CANCER REFERRAL Issued October 2012
Head and Neck- Two Week Wait Cancer Proforma
For General Dental Practitioners
Fax Number: (023) 92 681701 /
GP Name &
Address
Date of GDP Decision To Refer ……/…../……
Is the patient aware of their condition /suspected condition? Yes /No
Is the patient available to attend an Urgent 2WW appointment? Yes /No
CANCER CENTRE USE ONLY
Date & Time of Appointment / .…. / .…. / …...... : …..Date & Time Referral Received / .…. / .…. / …...... : …..
Date & Time Faxed Back to GP / .…. / .…. / …...... : …..
Details of any Appointments refused
URGENT CANCER REFERRAL Issued October 2012
Head and Neck- Two Week Wait Cancer Proforma
For General Dental Practitioners
Fax Number: (023) 92 681701 /
REFERRAL CRITERIA & REASON(S)
Your patient will be seen under the 2 week rule if one or more of the following criteria are present. Please tick the appropriate box(es) and add the relevant details below.
1 Unexplained neck lump or lump changing over 3-6 months (In patients with an unexplained lump in the neck which has recently appeared or a lump that has not been diagnosed before that has changed over 3-6 weeks)
2 Unexplained persistent swelling in the parotid or submandibular gland
3 Unexplained red and white patches of oral mucosa (Unexplained red & white patches (including suspected lichen planus) of the oral mucosas that are painful/swollen/bleeding – N.B a non-urgent referral should be made in the absence of these features. If oral lichen planus is confirmed, the patients should be monitored for oral cancer as part of routine dental examination)
4 Non healing ulcer or mass in mouth for 3 or more week’s duration
5 Unexplained tooth mobility persisting more than 3 weeks not associated with periodontal disease