BNSSG

GP REFERRAL FOR SUSPECTED SOFT TISSUE SARCOMA
On completion please attach to Choose & Book Referral. Please contact the number below if CAB unavailable
This form should only be used for suspected cancer and in conjunction with the NICE Referral Guidelines for Suspected Cancer, June 2005
Decision to refer date: UBRN:
Is patient aware that this is a suspected cancer referral? Yes No
If No, please state reasons why:
Has patient information leaflet been issued? Yes No
If No, please state reasons why:
Does the patient have availability within the next 14 days? Yes No
Please state any days which the patient is NOT available within the next two weeks:
Patient Details:
Surname:
Forename:
Address:
DOB:
Hosp No:
NHS No:
Contact Tel No: / Referring GP Details:
Name:
Practice:
Tel No:
Fax No:
Relevant Information: (Check as appropriate)
Suspected diagnosis: Primary Bone Tumour
Please refer all suspected primary bone tumours direct to the Oxford Orthopaedic Centre – the referral form can be found in the directory of services / Relevant Information: (Check as appropriate)
Suspected diagnosis: Soft Tissue Sarcoma
Site
Worrying features:
Size (> 5cm)
Size (please specify)
Increase in size
Deep to fascia
Pain
Investigations Undertaken:
Ultrasound MRI
Past Medical History, Medication and Allergies will automatically be included in form. Please enter any other significant additional information or attach relevant results/documentation to the UBRN in Choose & Book.
For Hospital Use (Referral Data)
Date received Date 1st appointment booked______
Date of 1st appointment______Date 1st seen______
Clinic Attending______
Specify reason if not seen at 1st appointment offered______
Final Diagnosis______Malignant / Benign
Was the referral appropriate Yes No (if no please give reason)______
Patient Details:
Surname:
Forename:
Hosp No:
NHS No:

Consultations within the last seven days:

Past Medical History:

Medication:

Allergies:

Should the Choose and Book system become unavailable, please contact your local CAB Lead.
NHS / 0117

Refer to:

UHB

NBT

Weston

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Last saved on Tuesday, 20 May 2014