ThamesValley
Cancer Network
2 Week Wait Referral for Suspected Prostate Cancer
Please attach to the Choose and Book Unique Booking Reference Number (UBRN) within 24 hours
Referral Receipt Date:
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Please Fax to Hospital Fax Number 01183226698
ThamesValley
Cancer Network
Patient Details
Name: «PATIENT_Forename1»«PATIENT_Surname»
Email Address:
First Language:
Address:
«PATIENT_BlockAddress»
Date of Birth: «PATIENT_Date_of_Birth»
Gender: «PATIENT_Sex»
Ethnicity:
Interpreter Required:
Tel (Daytime): «PATIENT_Main_Comm_No»
Tel (Work):
Tel (Mobile):
NHS No: «PATIENT_Current_NHS_Number»
Hospital No:
Page 1 of 3Vision v.0.7 – RBFT«PATIENT_Forename1»«PATIENT_Surname»«PATIENT_Current_NHS_Number»
Please Fax to Hospital Fax Number 01183226698
ThamesValley
Cancer Network
Page 1 of 3Vision v.0.7 – RBFT«PATIENT_Forename1»«PATIENT_Surname»«PATIENT_Current_NHS_Number»
Please Fax to Hospital Fax Number 01183226698
ThamesValley
Cancer Network
GP Details
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Please Fax to Hospital Fax Number 01183226698
ThamesValley
Cancer Network
GP Name:«REFERRAL_Clinician»
Address:«PRACTICE_Name»
«PRACTICE_BlockAddress»
Tel No:«PRACTICE_Main_Comm_No»
Fax No:
Date of referral:«SYSTEM_Date»
Page 1 of 3Vision v.0.7 – RBFT«PATIENT_Forename1»«PATIENT_Surname»«PATIENT_Current_NHS_Number»
Please Fax to Hospital Fax Number 01183226698
ThamesValley
Cancer Network
Page 1 of 3Vision v.0.7 – RBFT«PATIENT_Forename1»«PATIENT_Surname»«PATIENT_Current_NHS_Number»
Please Fax to Hospital Fax Number 01183226698
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.
Symptoms
Bone PainYes No
LUTSYes No
Symptoms possibly linked to metastasis (e.g. pain)Yes No
General symptoms (e.g. weight loss, lethargy)Yes No
Other, please specify
Family History of Cancer
Ca ProstateYes No
Details of family member (Father, brother, or son with prostate cancer)
Ethnic Origin
CaucasianHispanic
Afro-CaribbeanOther
Asian/Indian
Age Related Range(ARR) Please note:
Age PSA ( ng/ml)*Halve the figure if taking 5 reductase inhibitors [e.g. finasteride (
40-49>2.5Proscar/ Propecia) or dutasteride (Avodart)]
50-59>3.0*Lower thresholds (e.g. subtract 0.9 ug/L ) are appropriate in men with a family history or of Afro-
60-69>4.0Caribbean extraction
70-79>5.10
>80>10
Prostate examinationPrevious Negative Prostate Biopsy
Normal Yes No
Suspicious
Cancer likely
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Site – Move cursor to lump location & type X
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Please Fax to Hospital Fax Number 01183226698
Recorded PSA results with dates -Preferably 2 values at least 2 weeks apart, but if concerned refer with only 1 value
PSADate
Additional Information
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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 / anti-platelet therapy? Yes No
If yes, is it safe to stop this for up to 2 weeks?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 3Vision v.0.7 – RBFT«PATIENT_Forename1»«PATIENT_Surname»«PATIENT_Current_NHS_Number»
Please Fax to Hospital Fax Number 01183226698