ThamesValley
Cancer Network
2 Week Wait Referral for Suspected Urological Cancer (Excluding Prostate Cancer)
Please attach to the Choose and Book Unique Booking Reference Number (UBRN) within 24 hours
Referral Receipt Date:
Patient Details
Name: «PATIENT_Forename1»«PATIENT_Surname»Date of Birth: «PATIENT_Date_of_Birth»
Email Address:Gender: «PATIENT_Sex»
First Language:Ethnicity:
Address:Interpreter Required:
«PATIENT_BlockAddress»Tel (Daytime):«PATIENT_Main_Comm_No»
Tel (Work):
Tel (Mobile):
NHS No:«PATIENT_Current_NHS_Number»
Hospital No:
GP Details
GP Name:«REFERRAL_Clinician»Tel No:«PRACTICE_Main_Comm_No»
Address:«PRACTICE_Name»Fax No:
«PRACTICE_BlockAddress»Date of referral:«SYSTEM_Date»
Page 1 of 2 Vision v.0.5«PATIENT_Forename1»«PATIENT_Surname»«PATIENT_Current_NHS_Number»
Please Fax to Hospital Fax Number 01183226698
ThamesValley
Cancer Network
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 relevant details below.
BLADDER AND RENAL REFERRAL
Haematuria
Any agePainless macroscopic haematuria
Over 40Recurrent or persistent symptoms suggestive of urinary tract infection,
or loin pain, associated with haematuria
Over 50Unexplained microscopic haematuria
An abdominal massidentified clinically or on imaging that is thought to arise from the
urinary tract.
TESTICULAR
Swelling or mass in the testis, with or without pain
PENILE
Symptoms or signs of penile cancer. These include progressive ulceration or a mass in the
glans or prepuce particularly, but can involve the skin of the penile shaft (Lumps within the
corpora cavernosa can indicate Peyronie’s disease, which does not require urgent referral.)
Mandatory -A recent (within 3 months) renal function measurement must be included to prevent any delays with contrast CT scanning.
If you do not have this information please give the patient a bloods form for U&Es at referral
eGFR value: Date :
Additional Information
Page 1 of 2 Vision v.0.5«PATIENT_Forename1»«PATIENT_Surname»«PATIENT_Current_NHS_Number»
Please Fax to Hospital Fax Number 01183226698
Allergies«DRUG_ALLERGY»
Current Medication:«REPEATS»
Other Relevant Medical History:
Additional Information
Additional reasons for requesting this referral:
Is the patient on an anti-coagulant? Yes No
Please state if you are attaching a letter / computer printout with this information:Yes No
Is the Patient available for an appointment within the next 14 days: Yes No
Has the nature of this urgent referral been discussed with, and the Yes No
urgent two week wait referral leaflet given to, the patient:
1st OPA Required by:62 Day Breach Date:
Page 1 of 2«PATIENT_Forename1»«PATIENT_Surname»«PATIENT_Current_NHS_Number»
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