Nottingham NHS Treatment Centre
Flexi cystoscopy
Z017: Patient referral
Please attach the completed document using the Choose & Book system.
Section 1 Patient information (Please complete in BLOCK CAPITALS)
Surname:
Date of referral:
First name:
NHS number:
Mr
Miss
Mrs
Date of birth:
Address:
Ms
Other:
UBRN:
Home telephone number:
Mobile / daytime telephone number:
Transport: Yes
No
Mobility:
Interpreter: Yes
No
Ethnicity:
Postcode:
Language:
Section 2 Practice information (Please use practice stamp if available)
Referring GP:
Practice address:
Locum: Yes
No
Telephone:
Fax:
Postcode:
Section 3 Clinical information (please all applicable entries)
Please enclose print outs of CURRENT medications and PAST MEDICAL HISTORY
Suspected Cancer:
Kidney
Bladder and renal
Prostate
Testicular
Penile
Other
please specify
Symptoms:
None
Loin pain
Macroscopic Haematuria
Microscopic Haematuria if age ≥50 years
Bone Pain
Lower urinary tract (hesitancy, poor stream etc)
Testicular swelling
Other
please specify:
Clinical information:
Normal examination
Renal mass
Prostate feels malignant on
rectal examination
Swelling in body of testes
Penile skin lesion
Other
please specify
PSA ng/ml:
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Section 4 Past medical history
Section 5 Medication
Section 6 Additional clinical details
Discussed urgent suspected cancer referral with patient:
Yes
No
Is the patient aware they have been referred on the “2 Week Wait” pathway: Yes
Does the patient have any holiday plans within the next 2 months: Yes
If yes, please give details:
No
No
Age related PSA upper levels recommended by the Prostate Cancer Risk Management Programme
Age
ng/ml
Age
ng/ml
40-50 years
2.5
60-69 years
4.0
50-59 years
3.0
70+ years
5.0
CircleNottingham ¦ Nottingham NHS Treatment Centre ¦ Queen’s Medical Centre Campus ¦ Lister
Road ¦ Nottingham ¦ NG7 2FT
T: 0115 970 5800 extension 10010
F: 0115 978 8765
Contact: Emily.farrand@circlenottingham.co.uk
CircleNottingham is run on behalf of the NHS. CircleNottingham is a subsidiary of Circle Health Limited. Circle is the
registered trademark and trading name of Circle Health Limited.
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