Hospital Reference Code: OXOXO
2 Week Urgent Referral for Suspected Malignant Melanoma or Squamous
Cell Carcinoma only
Non-urgent referral - Basal cell carcinomas are slow growing, usually without significant expansion over two
months, and usually occur on the face. If basal cell carcinoma is suspected, refer non-urgently
To make a referral, FAX this form to the Suspected Cancer Referral Team on 01753 849200
Please note that this form will be audited for completeness
Patient Details
Surname:
Forename:
Address:
Please select number(s) for use in the next 24 hours:
Home Telephone:
Work Telephone:
Mobile Telephone:
Other (relative/next of kin):
Date of Birth:
Gender:
Ethnicity:
NHS Number:
Hospital Number:
First Language:
Interpreter
Required
X
Is the patient aware this is
a suspected cancer
referral?
Is the patient available for
an appointment within the
next 14 days?
Is the patient available for
for 62 days from date of
referral?
Has the patient been given
a 2 week wait leaflet?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
GP Details
GP Name:
Address:
Telephone Number:
Fax Number:
Date of Referral:
Date Referral
Received:
Melanoma - Urgent Referral: 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 - Urgent Referral
Excision in primary care should be avoided
Larger than 1 cm with significant induration on palpation - Commonly
Non-healing keratinizing
found on the face, scalp or back of the hand with a documented
or crusted tumours
expansion over 8 weeks
Of a squamous cell carcinoma - It is essential to attach a copy of the
Histological diagnosis
histopathology report
Patient has had an organ transplant and has developed a new or
Organ transplant
growing cutaneous lesions - squamous cell carcinoma is common
with immunosuppression but may be atypical and aggressive
Location e.g. Leg/Back
Size
cm
Diagnosis of SCC confirmed on biopsy? Yes
No
Please state if you are attaching a letter / computer printout with this information (please
telephone the GP referrer if extra information is required):
Mobile number of referring GP if appropriate:
Is the patient on anti-coagulant or anti-platelet medication?
«REPEATS»
«DRUG_ALLERGY»
Additional Information
Reviewed July 2015
Yes
No
Yes
No
Reviewed July 2015