PLEASE USE 2WW SERVICE ON CHOOSE AND BOOK OR FAX TO 01823 343 417 (MPH) OR 01935 384 640 (YDH)
This form should only be used for patients who meet the NICE referral criteria for suspected cancer (2005).All other referring symptoms
should be referred by Choose and Book or letter. Do not use this form for non-suspected cancer referrals
Decision to refer date (to be completed by GP ) : Referral received date (to be completed by hospital ) :
Has the patient been informed that they are being referred for suspected cancer?
Has the patient been given the 2WW referral patient information leaflet?
Yes
Yes
Please inform the patient that they will be offered an appointment / test within 14 days of receipt of referral
Dates patient is unavailable in next 14 days:
Patient Details:
Surname:
Forename:
Address:
Post Code:
Daytime Tel No:
Mobile Tel No:
NHS No:
Hosp No:
DOB:
If USS has been performed please attach* report
Patients must meet one or more of the following criteria:
OVARY :
Palpable abdominal or pelvic mass not obviously fibroids
Suspicious pelvic mass on ultrasound
NB: Please take CA125 blood test at time of referral to speed diagnosis, and confirm taken here
Women under 40 years require hCG, AFP and LDH in addition
Referring GP Details:
Name:
Practice:
Telephone No:
Fax No:
E-mail Address:
Date of USS:
No
No
UTERUS:
Not on HRT with postmenopausal bleeding
Persistent or unexplained postmenopausal bleeding after cessation of HRT for 6 weeks
Taking Tamoxifen with postmenopausal bleeding
CERVICAL:
Clinical features suggestive of cervical cancer examination
Persistent post coital bleeding with negative pelvic
VULVA:
Unexplained vulval lump
Vulval bleeding due ulceration
Persistent vulval prurititis or pain despite treat, watch and wait
EARLY REFERRAL: request for referral for any of the symptoms below should be made by Choose and Book or letter to the
Gynaecology Department and not using this form:

Abnormal peri-menopausal bleeding (in woman > 45 years)

Two or more unscheduled bleeds on HRT

Any routine cervical smear test which has a severe / moderate dyskariosis and / or glandular neoplasia

Persistent post coital bleeding in woman < 35 years

Consider non urgent gynaecology review if no suspicious lesions to suggest cancer on vulva
WHO Performance Status: 0 1 2 3 4 (circle) (0: fully active; 1: able to carry out light work; 2: capable of self care, up and about more than 50% of waking hours; 3: only limited self care, confined to bed or chair; 4: completely disabled, no self care ability)
Please attach* additional clinical details to include:
 significant medical history
 co-morbidities
 current medication clearly indicating if the patient is receiving any anti coagulation therapy.
 recent blood results (as indicated above)
 any other relevant information
Please note that referrals received without adequate supporting clinical information and relevant blood results cannot be processed and will be returned to the referrer as incomplete
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