DOB:
NHS no:
SUSPECTED SKIN CANCER REFERRAL FORM
Press the <Ctrl> key while you click here 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
North Middlesex
Princess Alexandra
Royal Free
UCLH
Whipps Cross
Whittington
Phone
Fax
Email: use <Ctrl> key + click on link
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
RF-tr.bcf2weekwaitreferrals@nhs.net
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
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 Skin Cancer Referral Form
(Version: MSW1.1; 17/06/2015)
Page 1 of 3
DOB:
NHS no:
CLINICAL DETAILS
If low suspicion of skin cancer, please monitor the patient for 8 weeks prior to referral.
Suspected Basal Cell Carcinoma requires urgent outpatient referral NOT 2 week wait referral.
MELANOMA
Each major feature scores 2 points. Each minor feature scores 1 point. Tick the relevant boxes below
as they apply to the patient. Add up the scores. Suspicion is greater for total of 3 points or more.
But strong concerns about any features should prompt a referral even if the score is lower.
Major Features
Growing in size
Minor Features
Irregular shape
Irregular colour
Largest diameter 7 mm
Change in sensation
Raised
Diagnosis of melanoma is:
Oozing
Bleeding
Firm to touch
Inflammation
Itching
Probable
Certain
Possible
SQUAMOUS CELL CARCINOMA
Note: These are commonly on the face, scalp or back of hand and larger than 1cm in diameter
Site of lesion:
Duration of lesion:
Please tick the relevant boxes below if they apply to the patient:
Pain/Tenderness
Crusting non-healing lesion with induration
Documented expansion over 8 weeks
Risk Factors
Organ transplant
Photodamaged skin
Immunosuppressive therapy
Previous skin cancer
Any other relevant symptoms or signs not covered by the guidelines:
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 click here to view the leaflet
FBC
ESR
CRP
Suspected Skin Cancer Referral Form
(Version: MSW1.1; 17/06/2015)
Page 2 of 3
DOB:
NHS no:
U&E
eGFR
LFTs
BONE PROFILE
SERUM CALCIUM
PAST MEDICAL HISTORY
ALLERGIES
MEDICATION
Suspected Skin Cancer Referral Form
(Version: MSW1.1; 17/06/2015)
Standard NHS Referral Form Layout created by Dr Ian Rubenstein
Page 3 of 3