DOB: NHSno:

Suspected Gynaecological Cancer Referral Form

Press the <Ctrl> key while you here to VIEW REFERRAL GUIDELINES

Suspected Gynaecological Cancer Referral Form Page 1 of 2

(Version: Test 12; Released: 15/12/2014)

DOB: NHSno:

REFERRALDATE:

Suspected Gynaecological Cancer Referral Form Page 1 of 2

(Version: Test 12; Released: 15/12/2014)

DOB: NHSno:

For Choose and Book referrals, attach this template to a referral in Choose and Book within 24 hours of creating the request - an appointment must be made for the patient before they leave the practice.

Press the <Ctrl> key while you click here to VIEW LEAD CLINICIAN CONTACT INFORMATION

Please X the corresponding box for the hospital the referral is being made to and fax/send within 24 hours.

Hospital / Phone / Fax / Email: select & copy OR <Ctrl>+click
Barnet / 0208 370 9079 / 020 8375 1977 /
Chase Farm / 0208 370 9079 / 020 8375 1977 /
BHRUT / 01708 435 065 / 01708 435 074/367
Barts & London / 020 7767 3333 / 020 3594 3278
Homerton / 020 8510 5099 / 0020 8510 7832 /
Newham / 020 7363 8817 / 020 7363 8818
North Middlesex / 020 8887 2661/2662/3390 / 020 8887 2663 /
Princess Alexandra / 01279 827 550 / 01279 827 171 /
Royal Free / 020 7433 2973/4 / 020 7433 2950/1
UCLH / 020 3447 9599 / 020 3447 9932 /
Whipps Cross / 020 8535 6856 / 020 8928 8836
Whittington / 020 7288 3736/3542 / 020 7288 5621 /

Patient has previously visited selected hospital HOSPITALNo:

PATIENT DETAILS

Suspected Gynaecological Cancer Referral Form Page 1 of 2

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SURNAME: FIRSTNAME: TITLE:

GENDER: DOB: NHSNO:

ETHNICITY: LANGUAGE:

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INTERPRETER REQUIRED TRANSPORT REQUIRED

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PATIENTADDRESS: POSTCODE:

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DAYTIMECONTACT':

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HOME': MOBILE': WORK':

EMAIL:

OPTIONAL DETAILS

ACCESS DETAILS: (e.g. Keypad number, someone to phone, neighbour)

CARER DETAILS: (Title + Name + Relationship)

NEXT OF KIN DETAILS: (Title + Name + Relationship)

GP DETAILS

USUALGPNAME:

PRACTICENAME:

PRACTICEADDRESS:

Suspected Gynaecological Cancer Referral Form Page 1 of 2

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BYPASS':

Suspected Gynaecological Cancer Referral Form Page 1 of 2

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MAIN': FAX: EMAIL:

REFERRING SERVICE DETAILS

REFERRINGSERVICENAME:

REFERRINGSERVICEADDRESS:

REFERRING SERVICE CONTACT DETAILS

MAIN': FAX: EMAIL:

THIS REFERRAL IS FROM

GP Referring Service

REFERRINGCLINICIAN:

Suspected Gynaecological Cancer Referral Form Page 1 of 2

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CLINICAL DETAILS

REASON FOR REFERAL
Lesion suspicious of cancer on cervix or vagina on speculum examination or smear suggesting cancer urgently refer to colposcopy rather than via 2WW
Lesions suspicious of cancer on clinical examination of vulva or vagina
Ascites/pelvic mass on examination/ultrasound (not obviously fibroids/urological/GI)
Raised CA 125 and strong clinical suspicion of ovarian cancer (with USS if available)
Persistent intermenstrual bleeding (IMB) in women over 45 years of age with normal vaginal examination (lasting more than 6 weeks after stopping HRT/COCP if taken)
Postmenopausal Bleeding
HRT: Unexpected or prolonged bleeding for more than 6 weeks after stopping HRT

Any other relevant symptoms or signs not covered by the guidelines:

Duration of symptoms:

Family history of cancer including age at diagnosis:

Information given to patient:

I confirm that I have discussed the possibility with the patient that the diagnosis may be cancer
I confirm that I have explained the two week wait appointment process to the patient

Please hand the patient a copy of the URGENT REFERRALS PATIENT INFORMATION LEAFLET

Press the <Ctrl> key while you here to view the leaflet

Suspected Gynaecological Cancer Referral Form Page 1 of 2

(Version: Test 12; Released: 15/12/2014)

DOB: NHSno:

CLINICALLY-SPECIFIC AUTOMATIC TABULATED DATA

IMAGING STUDIES Please include date: and location:

Suspected Gynaecological Cancer Referral Form Page 1 of 2

(Version: Test 12; Released: 15/12/2014)

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ROUTINE AUTOMATIC TABULATED DATA

PAST MEDICAL HISTORY

ALLERGIES

MEDICATION

OFFICE USE ONLY

Suspected Gynaecological Cancer Referral Form Page 1 of 2

(Version: Test 12; Released: 15/12/2014)