LUNG – Suspected Cancer TWR referral form
Please fax this form back within 24 hours of seeing the patient for 24 hospital appointment within 14 days
PATIENT’S DETAILS
GP’s DETAILS
Surname
First name(s)
Address
GP’s name
Surgery name
Surgery address
Date of birth
Surgery telephone:
Home telephone:
Surgery fax:
Mobile/Work telephone:
NHS number:
Hospital number:
Patients with STRIDOR or SIGNS of SUPERIOR VENA CAVAL OBSTRUCTION (i.e. swollen face/neck with fixed
jugulat venous pressure elevation) ADMIT IMMEDIATELY
URGENT TWR REFERRAL CRITERIA
TICK
Persistent haemoptysis in smokers or ex-smokers aged 40 or older
A chest X-ray suggestive of lung cancer including pleural effusion and slowly resolving
consolidation
A normal x-ray where there is a high suspicion of lung cancer
A history or asbestos exposure with recent onset chest pain/breathlessness/unexplained
systemic symptoms, where a chest x-ray indicates pleural effusion, pleural mass or any
suspicious lung pathology
RENAL FUNCTION – PLEASE ENSURE THAT ONE OF THE TWO BOXES IS COMPLETED
PLEASE NOTE THAT THE REFERRAL WILL NOT BE ACCEPTED WITHOUT THIS INFORMATION
eGFR in the last 2 months ________ mL/min
If no eGFR within last 2 months, please arrange
Date:
bloods to be taken prior to referral.
Date of blood test:
PATIENTS WHO NEED AN URGENT X-RAY (REPORTED WITHIN 5 DAYS) INCLUDE:
Unexplained or persistent (longer than 3 weeks)
 Haemoptysis
 Chest and/or shoulder pain
 Neck or supraclavicular lymph
nodes
 Dyspnoea
 Underlying chronic
 Cough
 Weight loss
respiratory problems with
 Features suggestive
unexplained changes in
 Chest signs
metastasis from lung cancer
existing symptoms
 Hoarseness
(brain/bone/liver/skin etc)
 Finger clubbing
ADDITIONAL MANDATORY CLINICAL INFORMATION REQUIRED:
Attach summary of past medical history, medication and allergies
Summary of past medical history, medication and allergies attached?
I have told this patient I am referring them under the TWR and have explained this process
Referral letter attached?
Referral date:
GP signature
TICK
TO MAKE A REFERRAL TO FRIMLEY PARK HOSPITAL, fax this form and any additional correspondence to:
01276 604506