Fax: 020 8375 1977
Tel: 020 8370 9079 / Chase Farm
Fax: 020 8375 1977
Tel: 020 8370 9079 / BHRUT
Fax:01708 435 074/ 01708 435 367
Tel: 01708 435 065 / Barts & the London
Fax:0203 594 3278
Tel: 0207 767 3333
Homerton
Fax: 020 8510 7832
Tel: 020 8510 5099 / North Middlesex
Fax: 020 8887 2663/4
Tel: 020 8887 2662 / Princess Alexandra
Fax: 01279 827 171
Tel: 01279 827 550 / Royal Free
Fax: 020 7433 2950
Tel: 020 7443 9757
UCLH
Fax: 020 3447 9932
Tel: 020 3447 9599 / Whipps Cross
Fax: 020 8928 8836 Tel: 020 8535 6856 / Whittington
Fax: 020 7288 5621
Tel: 020 72885511/12
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:
Date referral received:
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 patient’s preferred contact phone details / Home:
Daytime:
REFERAL INFORMATION (Must be completed): *
NB – Suspected Basal cell carcinoma – prompt outpatient referral not 2 week wait referral
SUSPECTED DIAGNOSIS: If low suspicion monitor 8 weeks before referral
Melanoma (please tick) Major features 2 points, minor features 1 point. Suspicion is greater for 3 points or more
Probable / Possible / Definite
Site of Lesion: Duration of lesion:
Major Features:
Growing in size / Irregular shape / Irregular colour
Minor Features:
Largest Diameter 7mm / Oozing / Inflammation
Change in sensation / Bleeding / Itching
Squamous Cell Carcinoma(please tick)
Probable / Possible / Definite
Site of Lesion: Duration of lesion:
Squamous Cell Carcinoma CharacteristicsCommonly face, scalp, back of hand>1cm:
Crusting non-healing lesion with induration / Documented expansion over 8 weeks
Pain/Tenderness
Risk Factors:
Organ Transplant / Immunosuppressive Therapy
Photodamaged Skin / Previous Skin Cancer
Any other relevant symptoms not covered by the guidelines:
Past Medical History:
Medication:
I confirm that I have discussed the possibility with the patient that the diagnosis may be cancer
PLEASE INCLUDE YOUR REFERRAL LETTER IF APPROPRIATE WITH THIS PROFORMA INCLUDING PAST MEDICAL HISTORY, MEDICATIONS AND BLOOD RESULTS
If you wish to discuss clinical matters relating to the two week wait referral please contact:
BarnetHospital / Dr Howard Stevens or Dr Penny Thomson (Via secretary):020 8216 5489
Central Office (referrals): 02083751907
ChaseFarmHospital / Dr Howard Stevens or Dr Penny Thomson(Via secretary)
020 8375 1999
Barking, Havering and Redbridge University Hospitals NHS Trust / Cancer Referrals Office: 01708 435065
Barts and the London Hospital / Skin Department Reception020 3594 2069/2071
Jill (secretary) 02035942124
On-call doctor via switchboard (020 3416 5000)
Homerton University Hospital NHS Foundation Trust / Dr Richard Bull, Consultant Dermatologist: 020 8510 7690
Dr Portia Goldsmith, Consultant Dermatologist: 020 8510 7690
Dr Lucia Pozo-Garcia, Consultant Dermatologist: 020 8510 7690
Dr Virginia Hubbard, Consultant Dermatologist: 020 8510 7388
North Middlesex University Hospital NHS Trust / Dr Nick Mann (Secretary): 020 8887 2426
Princess Alexandra Hospital NHS Trust / Fast Track Office:01279 827 550
Royal Free London NHS Foundation Trust / Dr David Chao (Secretary): 020 7830 2376 ext. 38133
University College London NHS Foundation Trust / Dr Conal Perrett: 020 3447 9224
Whipps Cross University Hospital / Central Office - 02085395522 x6449 (main number for GPs)
Dr Anshoo Sahota, Consultant (Lead Clinician):
020 8539 5522 ext 5135
Dr Anthony Bewley, Consultant020 8539 5522 ext. 5248
Dr Karen Gibbon, Consultant 020 8539 5522 – ext. 5097
Josie Murphy, CNS:020 8539 5522 Bleep 681
Jane Watts,CNS:020 8539 5522 – Bleep 426
The Whittington Hospital NHS Trust / Dr Kathy Taghipour (secretary): 020 7288 5266
Or
Lucy Reeves Skin CNS: 020 7288 5062
Or
GP Referral Line: 020 7288 3070
London Cancer 2ww Skin referral form Page 1 of 3