Thames Valley
Cancer Network
2 Week Wait Referral for Suspected Malignant Melanoma or
Squamous Cell Carcinoma
Non-urgent referral - Basal cell carcinomas are slow growing, usually without significant expansion over 2 months and usually occur on the
face. If basal cell carcinoma is suspected, refer non-urgently
Please attach to the Choose and Book Unique Booking Reference Number (UBRN) within 24 hours
Referral Receipt Date:
Patient Details
Name: «PATIENT_Forename1» «PATIENT_Surname»
Email Address:
First Language:
Address:
«PATIENT_BlockAddress»
Date of Birth: «PATIENT_Date_of_Birth»
Gender:
«PATIENT_Sex»
Ethnicity:
Interpreter Required:
Tel (Daytime): «PATIENT_Main_Comm_No»
Tel (Work):
Tel (Mobile):
NHS No:
«PATIENT_Current_NHS_Number»
Hospital No:
GP Details
GP Name:
Address:
«REFERRAL_Clinician»
«PRACTICE_Name»
«PRACTICE_BlockAddress»
Tel No:
«PRACTICE_Main_Comm_No»
Fax No:
Date of referral: «SYSTEM_Date»
Date Referral Received:
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 relevant details below.
Melanoma
Excision in primary care should be avoided
(If you have excised a clinically unsuspected melanoma, it is essential to attach a copy of the histopathology report )
With a lesion suspected to be melanoma, including change in
size / shape / colour, irregular outline, itchy / oozing / crusting or
inflamed
Squamous cell carcinomas
Excision in primary care should be avoided
Non-healing keratinizing or crusted tumours
Larger than 1 cm with significant induration on palpation –
Commonly found on the face, scalp or back of the hand with
a documented expansion over 8 weeks
Histological diagnosis
Of a squamous cell carcinoma - It is essential to attach a copy
of the histopathology report
Page 1 of 2 Vision v.0.7
«PATIENT_Forename1» «PATIENT_Surname» «PATIENT_Current_NHS_Number»
Please Fax to Hospital Fax Number 01183226698
Thames Valley
Cancer Network
Organ transplant
Patient has had an organ transplant and has developed a
new or growing cutaneous lesions - squamous cell
carcinoma is common with immunosuppression but
may be atypical and aggressive
Location e.g. Leg/Back
Size:
Diagnosis of SCC confirmed on biopsy?
Yes
cm
No
Mandatory - A recent (within 3 months) renal function measurement must be included to prevent any delays with
contrast CT scanning.
If you do not have this information please give the patient a bloods form for U&Es at referral
eGFR value:
Date :
Additional Information
Allergies
«DRUG_ALLERGY»
Current Medication:
«REPEATS»
Other Relevant Medical History:
Additional Information
Additional reasons for requesting this referral:
Is the patient on an anti-coagulant?
Yes
No
Please state if you are attaching a letter / computer printout with this information: Yes
No
Is the Patient available for an appointment within the next 14 days:
Yes
No
Has the nature of this urgent referral been discussed with, and the
urgent two week wait referral leaflet given to, the patient:
Yes
No
1st OPA Required by:
62 Day Breach Date:
Page 2 of 2 Vision v.0.7
«PATIENT_Forename1» «PATIENT_Surname» «PATIENT_Current_NHS_Number»
Please Fax to Hospital Fax Number 01183226698