Head and Neck Cancer – 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
Surname
First name(s)
Address
Date of birth
Home telephone:
Mobile/Work telephone:
NHS number:
Hospital number:
REFERRER’S DETAILS
(General Medical Practitioner or General Dental
practitioner)
Name
Surgery address
Surgery telephone
Surgery fax
GP’s Details (if not already included above)
GP’s name
Surgery name
Surgery address
Surgery telephone:
Surgery fax:
URGENT TWR REFERRAL CRITERIA
Suspected site – Please tick as appropriate
Mouth (inc. lip)
Throat
Neck Lump incl LN
Salivary
Thyroid
Other
glands
Possible Head and Neck Cancer
TICK
Unexplained lump in neck of recent onset or an existing lump changing size in last 3-6 weeks
Unexplained persistent swelling in parotid or submandibular gland
Unexplained persistent sore of painful throat with or without dysphagia
Unilateral unexplained head/neck pain for more than 4 weeks, with otalgia but normal otoscopy
Unexplained ulceration or mass of oral mucosa persisting for more than 3 weeks
Unexplained red and white patches of the oral mucosa that is painful or swollen or bleeding
Hoarseness for more than 6 weeks
Possible Thyroid Cancer
Patients with symptoms of tracheal compression, including stridor due to thyroid swelling: ADMIT IMMEDIATELY
Solitary Thyroid Nodule getting larger
Thyroid swelling &unexplained hoarseness
Thyroid swelling and Hx neck irradiation
Thyroid swelling and cervical lymphadenopathy
Thyroid swelling and FHx endocrine tumour
Thyroid swelling pre-puberty or aged >65 years
ADDITIONAL MANDATORY CLINICAL INFORMATION REQUIRED:
TICK
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:
Referrer’s signature
TO MAKE A REFERRAL TO FRIMLEY PARK HOSPITAL, fax this form and any additional correspondence to:
01276 604506