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>+clickBarnet / 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
(Version: Test 12; Released: 15/12/2014)
DOB: NHSno:
SURNAME: FIRSTNAME: TITLE:
GENDER: DOB: NHSNO:
ETHNICITY: LANGUAGE:
Suspected Gynaecological Cancer Referral Form Page 1 of 2
(Version: Test 12; Released: 15/12/2014)
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INTERPRETER REQUIRED TRANSPORT REQUIRED
Suspected Gynaecological Cancer Referral Form Page 1 of 2
(Version: Test 12; Released: 15/12/2014)
DOB: NHSno:
PATIENTADDRESS: POSTCODE:
Suspected Gynaecological Cancer Referral Form Page 1 of 2
(Version: Test 12; Released: 15/12/2014)
DOB: NHSno:
DAYTIMECONTACT':
Suspected Gynaecological Cancer Referral Form Page 1 of 2
(Version: Test 12; Released: 15/12/2014)
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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
(Version: Test 12; Released: 15/12/2014)
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BYPASS':
Suspected Gynaecological Cancer Referral Form Page 1 of 2
(Version: Test 12; Released: 15/12/2014)
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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
(Version: Test 12; Released: 15/12/2014)
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CLINICAL DETAILS
REASON FOR REFERALLesion 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 cancerI 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)
DOB: NHSno:
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)