Skin Health Service Referral Form s1
Skin Health Service Referral Form
(Please complete the relevant pages in full. Failure to do so may delay the application)
(Please refer suspected Squamous Cell Carcinoma or Malignant Melanoma and other non BCC suspected skin cancers as a two week wait. Refer to attached guidelines.)
Patient Details: / GP Details:NHS No: / NHS Number / Name:
Date of Birth: / Date of Birth / GP Practice: / The Baldock Surgery
Male / Female: / Gender / Address: / Astonia House High Street
Baldock Hertfordshire
Mr / Mrs / Miss / Other (please state): / Title
Surname: / Surname / Post Code: / SG7 6BP
First Name: / Given Name / Tel No. / 01462 892458
Address: / Home Full Address (single line) / Fax No. / 01462 490821
Post Code: / Home Address Postcode / Mental Capacity:
Tel No. / Patient Home Telephone / Does this patient have capacity / Yes / No
Mobile No. / Patient Mobile Telephone
Details of skin condition/ lesion (not including suspected cancers - for suspected BCC instead complete box below and for suspected SCC or malignant melanoma please refer as two week wait on 2 week wait form)
Description:
Site:
Size (mm):
Further information (including why lesion cannot be managed in GP surgery, how patient meets referral criteria or exceptionality):
Suspected BCC:
Size (mm):
Site - in particular if on face describe if close to eyes, nose lips or ears (diagram if possible).
Is patient immunosuppressed or has Gorlin’s Syndrome? Yes / No.
If yes, please give details:
Is the BCC/ suspected BCC overlying an important underlying structure (artery or vein)? Yes / No.
If yes, please give details:
Is this a recurrent BCC? Yes / No.
Relevant Medical History:
Relevant Investigations / Results / Blood Tests etc.
Current Medication Including Anticoagulants
Send UBRN notification via email to:
OR /
Send Referral via Fax No. / 01438 712381
Telephone No. for queries only / 01438 841848
Please note that inappropriate referrals which do not meet the referral guidelines and/or the Beds and Herts priorities forum guidance or do not state sufficient exceptional circumstances will be sent back to the referring GP.