To Make a Referral, FAX This from to Moorfields Booking Centre Within 24 Hours of The

To make a referral, FAX this from to Moorfields Booking Centre within 24 hours of the decision to refer.

You may also fax an accompanying letter if you wish to do so.

This form should NOT be used for suspected basal cell carcinomas which should be referred to the Eyelid Oncology Services at Moorfields Eye Hospital in the usual way.

Fax to: 0207 566 2073

PATIENT DETAILS (Please complete in block capitals) / GP DETAILS(Please complete in block capitals)
Forename:
Surname:
Address:
Post code:
Date of Birth://
Sex: M F
NHS Number:
Has the patient previously visited the hospital?
Y N
Hospital Unit Number:
Interpreter required: Y N
Language: / Date referral sent:
Name of referrer:
Address:
Post code:
Phone number:
Fax number:
IMPORTANT: To be able to contact the patient within 48 hours of referral (day and evening), please provide patients preferred contact phone details / Home:
Mobile:
Work:
REFERAL INFORMATION (Must be completed)
REFERRING CONSULTANT
Name: Organisation:
Address:
Tel no: Fax no:
Is patient on open cancer pathway?
If yes: 31 day 62 day
Breach date (if known):
N.B If this is a confirmed cancer referral from secondary care, the inter-provider transfer form must also be provided
REFERRAL INFORMATIONmust be completed
Diagnosis: / Lid Tumour / Probable
Orbital Tumour / Possible
Conjunctival Tumour / Definite
Has the patient been informed of diagnosis?
Lid Tumour / Malignant melanoma / Squamous cell carcinoma/other
Duration (months): / Size (mm): / Site (draw):
R

/ L



Malignant melanoma: / Squamous cell Carcinoma/ other:
Growing in size / Crusty/ not healing
Changing shape / Bleeding
Changing colour / Growing in size
Inflamed / Palpable lymph nodes
Ulceration/bleeding / Organ transplantation
Palpable lymph nodes / Immunosuppressive therapy
Orbital tumour
Site: / Right / Symptoms: / Vision loss/change
Left / Diplopia
Proptosis/ globe displacement
Duration (months):
CT/ MRI
Previous biopsy / If Y, diagnosis:
Conjunctival tumour:
Symptoms: / Red eye
Non-resolving conjunctivitis
Symptom duration (months):
Site (click a box to mark diagram): / R
/ L

Previous biopsy or surgery? / If Y diagnosis:
Information given to Patient
Family History of cancer including age of their diagnosis:
Any other relevant symptoms not covered by the guidelines:
I confirm that I have discussed the possibility with the patient that the diagnosis may be cancer

PLEASE INCLUDE WITH THIS PROFORMA PAST MEDICAL HISTORY, MEDICATIONS AND RESULTS AND YOUR REFERRAL LETTER IF APPROPRIATE

If there are any administrative issues with this form please contact:

Moorfields Eye Hospital NHS Foundation Trust / Moorfields Booking Centre:
Either via CAB as electronic referral or faxed paper referral Booking Centre
Tel: 020 7566 2357.

If you wish to discuss any clinical issuesrelating to this referral please contact:

Moorfields Eye Hospital NHS Foundation Trust / Secretary for the Lead Consultant for the Lid Oncology Service
Tel: 020 7566 2010.

London Cancer 2wwEye referral form

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