URGENT CANCER REFERRAL
Issued October 2012
Head and Neck- Two Week Wait Cancer Proforma
For General Dental Practitioners
Fax Number: (023) 92 681701
PATIENT DETAILS
NHS No
REFERRING GDP PRACTICE DETAILS
Referring
DENTIST
Practice Name
Practice Code
Practice Address
Previous Surname
Forename
Address
Post Code
Daytime Phone Number
Evening Phone Number
Mobile Phone Number
Practice Post Code
Practice Phone No
Practice Fax No
GP Name &
Address
Date of GDP Decision To Refer ……/…../……
Is the patient aware of their condition /suspected condition? Yes /No
Is the patient available to attend an Urgent 2WW appointment? Yes /No
CANCER CENTRE USE ONLY
Date & Time of Appointment
Date & Time Referral Received
Date & Time Faxed Back to GP
Details of any Appointments refused
.…. / .…. / …... ..... : …..
.…. / .…. / …... ..... : …..
.…. / .…. / …... ..... : …..
REFERRAL CRITERIA & REASON(S)
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 the relevant details below.
1 Unexplained neck lump or lump changing over 3-6 months (In patients with an unexplained lump in the neck which has
recently appeared or a lump that has not been diagnosed before that has changed over 3-6 weeks)
2 Unexplained persistent swelling in the parotid or submandibular gland
3 Unexplained red and white patches of oral mucosa (Unexplained red & white patches (including suspected lichen planus) of the
oral mucosas that are painful/swollen/bleeding – N.B a non-urgent referral should be made in the absence of these features. If oral lichen
planus is confirmed, the patients should be monitored for oral cancer as part of routine dental examination)
4 Non healing ulcer or mass in mouth for 3 or more week’s duration
5 Unexplained tooth mobility persisting more than 3 weeks not associated with periodontal disease
Current medication
Relevant PMH