URGENT SUSPECTED CANCER REFERRAL FORM

SUSPECTED MALIGNANT SOFT TISSUE TUMOUR IN ADULTS

Sarcoma Diagnostic Clinic

Patient Details
Full Name: / Address:
Other Names:
Sex:
Date of Birth:
NHS No.: / Home Phone No.:
Hospital No.: / Mobile Phone No.:
Interpreter Required? / Yes o /No o / Work Phone No.:
Transport required? / Yes o /No o / Preferred Phone No.:
Email Address:
* N.B. It is essential that you provide a current contact telephone number for the patient so that the Health Board can contact the patient within 24-hours to arrange a convenient appointment.
Practice Details
Referring GP:
Registered GP:
GMC Code:
Practice Name & Address:
Practice Code: / LHB Code: / 7A3
Tel No: / Fax No:
Date seen by GP: / Decision to refer date:
SOFT TISSUE SARCOMAS
Please refer patients to your local Sarcoma Diagnostic Clinic if one or more of the following symptoms apply. There is a palpable lump that is ANY of the following:
Greater than 5cm in diameter (a golf ball is about 4.2 cm) / Yes o /No o
Deep to fascia, fixed or immobile / Yes o /No o
Increasing in size rapidly / Yes o /No o
Painful / Yes o /No o
Clinical details regarding the suspicious lump (inc. location of lump):
Patient with suspected recurrence after previous resection should be referred to the Sarcoma Treatment Centre via fax to 01792 703875
NB: Patients with the following should be referred to the more appropriate specialist team for an urgent outpatient appointment using the Urgent Suspected Cancer Referral (USCR) form for that speciality:
·  Any patient with a neck lump that persists for more than three weeks to the local Head & Neck Team
·  Any patient with generalised lymphadenopathy or neck lumps with a lymphocytosis to the local Haematology Team
Details of ABMU Health Board Soft Tissue Sarcoma diagnostic Clinics
Please either:
·  Fax to 01792 703875
·  Or attach to generic e-referral template and send to Plastic Surgery in Morriston Hospital as an USC referral
Is the patient aware of the reason & urgency for referral & aware that they will be offered an appointment within 10 working days? Yes o /No o
Name of referrer (please print): / Signature:
………………....... / Date:

Soft Tissue Sarcoma Referral Form September 2011 Page 2 of 2