DOB:
NHS no:
SUSPECTED HAEMATOLOGICAL CANCER REFERRAL FORM
Press the <Ctrl> key while you here link to VIEW REFERRAL GUIDELINES
REFERRAL DATE:
For Choose and Book referrals, attach this template to a referral in Choose and Book within 24
hours of creating the request - an appointment must be made for the patient before they leave
the practice.
Press the <Ctrl> key while you click here to VIEW LEAD CLINICIAN CONTACT INFORMATION
Please X the corresponding box for the hospital the referral is being made to and fax/send within 24 hours.
Hospital
Barnet
Barts & London
BHRUT
Chase Farm
Homerton
Newham
North Middlesex
Princess Alexandra
Royal Free
UCLH
Whipps Cross
Whittington
Phone
Fax
Email: select & copy OR <Ctrl>+click
0208 370 9079
020 8375 1977
RF-tr.bcf2weekwaitreferrals@nhs.net
020 7767 3333
020 3594 3278
01708 435 065
01708 435 074/367
0208 370 9079
020 8375 1977
020 8510 5099
0020 8510 7832
020 7363 8817
020 7363 8818
020 8887 2661/2662/3390
020 8887 2663
Northmid.2weekwaitteam@NHS.net
01279 827 550
01279 827 171
tpa-tr.FastTrackReferrals@nhs.net
020 7433 2973/4
020 7433 2950/1
020 3447 9599
020 3447 9932
0208 539 5522 extensions
4348/4349/4350
020 7288 3736/3542
RF-tr.bcf2weekwaitreferrals@nhs.net
uclh.2ww@nhs.net
0208 928 8836
020 7288 5621
twowwbookings.whitthealth@nhs.net
Patient has previously visited selected hospital
HOSPITAL No:
PATIENT DETAILS
SURNAME:
GENDER:
FIRST NAME:
DOB:
ETHNICITY:
TITLE:
NHS NO:
LANGUAGE:
INTERPRETER REQUIRED
PATIENT ADDRESS:
TRANSPORT REQUIRED
POSTCODE:
DAYTIME CONTACT:
HOME:
MOBILE:
WORK:
EMAIL:
GP DETAILS
USUAL GP NAME:
PRACTICE NAME:
PRACTICE CODE:
PRACTICE ADDRESS:
BYPASS:
MAIN:
FAX:
EMAIL:
REFERRING CLINICIAN:
Suspected Haematological Cancer Referral Form
(Version: MSW1.1; 17/06/2015)
Page 1 of 3
DOB:
NHS no:
CLINICAL DETAILS
PLEASE NOTE THE FOLLOWING POINTS:
1. If acute leukaemia is suspected on blood test please telephone haematology IMMEDIATELY.
2. If spinal cord compression is suspected please refer IMMEDIATELY for investigation.
MALIGNANCY SUSPECTED
Myeloma – please include results of urinary Bence Jones protein and serum protein
electrophoresis studies plus any appropriate radiology
Leukaemia
Hodgkins or Non Hodgkins Lymphoma
SYMPTOMS
Night Sweats
Weight loss
Back pain with ‘Red Flags’
Other (please specify):
Itching
Breathlessness
Persistent bone pain
Bruising/Bleeding
Recurrent infections
EXAMINATION FINDINGS
Unexplained LN >1cm for 6 weeks
OR
Location of enlarged lymph nodes:
Unexplained LN >2cm
Unexplained splenomegaly
Other (please specify):
Any other relevant symptoms or signs not covered by the guidelines:
Duration of symptoms:
Family history of cancer including age at diagnosis:
I confirm that I have discussed the possibility with the patient that the diagnosis may be cancer
I confirm that I have explained the two week wait appointment process to the patient
Please hand the patient a copy of the URGENT REFERRALS PATIENT INFORMATION LEAFLET
Press the <Ctrl> key while you here link to view the leaflet
Please state hospital laboratory where blood tests performed:
FBC
ESR
U&E
LFT
SERUM PROTEIN ELECTROPHORESIS
Suspected Haematological Cancer Referral Form
(Version: MSW1.1; 17/06/2015)
Page 2 of 3
DOB:
NHS no:
URINARY BENCE JONES PROTEIN
IMAGING STUDIES
Please include date:
and location:
PAST MEDICAL HISTORY
ALLERGIES
MEDICATION
Suspected Haematological Cancer Referral Form
(Version: MSW1.1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
Page 3 of 3