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IF CHOOSE & BOOK IS UNAVAILABLE, COMPLETE FORM AND EMAIL/FAX TO THE REFERRAL TEAM WITHIN 24 HRS.
NOTE: This form is NOT for use for patients aged < 16 years.
PATIENT DETAILS –Must provide current telephone number.
Last name: First name:
Gender: M ☐ F ☐ DOB:
NHS No:
Address:
Telephone (Day):
Telephone (Evening):
Mobile No.:
Patient agrees to telephone message being left? Y ☐ N ☐
Transport required? Y ☐
Email:
Interpreter required? Y ☐ Language/Hearing:
Learning difficulties? Y ☐
Mental capacity assessment required? Y ☐
Known safeguarding concerns? Y ☐
Mobility requirements (unable climb on/off bed)? Y ☐
Basal cell carcinoma: Routine referral unless particular concern that delay may have significant impact because of site/size [2015]
SYMPTOMS & CLINICAL EXAMINATIONS
☐ Dermoscopy suggests melanoma of the skin [2015]
☐ Pigmented or non-pigmented skin lesion that suggests nodular melanoma [2015]
☐ Skin lesion raises suspicion of squamous cell carcinoma [2015]
Suspicious pigmented skin lesion with checklist score ≥3 [2015]
Major features (scoring 2 points each):
☐ change in size
☐ irregular shape
☐ irregular colour
Minor features (scoring 1 point each):
☐ largest diameter 7 mm or more
☐ inflammation
☐ oozing
☐ change in sensation TOTAL SCORE:
GP DETAILS
GP name:
Practice Code:
Address:
TEL:
FAX:
Practice email:
INVESTIGATIONS IN SUPPORT OF REFERRAL
Location of lesion:
Duration of lesion:
Size of lesion (mm):
PATIENT MEDICAL HISTORY
Existing conditions (inc. smoking status):
Risk factors:
☐ Prolonged UV exposure ☐ Family history
☐ Multiple/atypical naevi ☐ Fair skin/poor tanning
☐ Immunosuppression and new/growing lesion
Current medication (attach list & indications):
Allergies Y ☐
Anticoagulants/Antiplatelets Y ☐
Immunosuppressants Y ☐
Diabetic Y ☐
WHO Patient Performance status (see key below)
☐ 0 ☐ 1 ☐ 2 ☐ 3 ☐ 4
DISCUSSIONS WITH PATIENT PRIOR TO REFERRAL
Cancer needs to be excluded ☐
Patient given referral information leaflet ☐
Date(s) unavailable next 14 days:
Please attach a Patient Summary including:
☐ Referral letter (if applicable) ☐ Investigation results ☐ PMH ☐ Up-to date medications list and indications
If your patient does not meet NICE suspected cancer referral criteria, but you feel they warrant further investigation, please disclose full details in your referral letter.
WHO PATIENT PERFORMANCE STATUS KEY
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out light/sedentary work, e.g. house or office work.
2 Ambulatory and capable of self-care, but unable to carry out work activities. Up and active > 50% of waking hours.
3 Capable of only limited self-care. Confined to bed or chair >50% of waking hours.
4 Completely disabled. Cannot carry out any self-care. Totally confined to bed or chair.
FOR FURTHER GUIDANCE ON LOW RISK SYMPTOMS & HOSPITAL CONTACT DETAILS, SEE REVERSE OF THIS FORM.

Presents with any of the following:
Suspicious pigmented skin lesion with checklist total score ≥3
Major features (2 points):
− change in size
− irregular shape
− irregular colour
Minor features (1 point):
− largest diameter ≥ 7 mm
− inflammation
− oozing
− change in sensation
Skin lesion raises suspicion of squamous cell carcinoma [2015]
Pigmented or nonpigmented lesion that suggests nodular melanoma [2015]
Past history of a transplant and a new or growing skin lesion
Dermoscopy suggests melanoma of the skin [2015]
YES
Skin lesion that raises suspicion of a basal cell carcinoma [2015]
(usually on the face)
If there is particular concern that delay may have a significant impact, because of lesion site/size [2015]
NO
Non-urgent referral
Persistent or slowly evolving unresponsive skin conditions, where diagnosis is uncertain and cancer is a possibility
Refer to dermatologist
Features suggestive of a basal cell carcinoma include:
• An ulcer with raised, rolled edge,
• Prominent fine blood vessels around the lesion,
• Nodules, often waxy or pearly in appearance.
Suspected BCCs should only be excised in primary care in accordance with the NICE guidance on Improving Outcomes for People with Skin Tumours including melanoma (May
2010). Specific sites of concern are sun-exposed areas such as the scalp, face, hands and arms, particularly in fair-haired patients. (Macmillan Rapid Referral Guidelines, July 2015)
Essex
Basildon & Thurrock
FAX: 01268 598066 cancer.2wwreferrals@btuh.nhs.uk
Anglia
Addenbrookes
Add-tr.nhsoutpatientreferrals@nhs.net
TEL: 01223 274593
Bedford Hospital
FAX: 01234 792133
Hinchingbrooke
TEL: 01480 847557 hch-tr.cancerMDT@nhs.net
Ipswich Hospital
FAX: 01473 704120
James Paget
FAX: 01493 453325
QEH, King’s Lynn
FAX: 01553 613473
Norfolk & Norwich
FAX: 01603 286876
Peterborough & Stamford
FAX: 01733 678562
2wwreferrals@pbh-tr.nhs.uk
West Suffolk Hospital wsh-tr.RapidAccess@nhs.net
Beds & Herts
East & North Herts
FAX: 01438 284503
If you have not received acknowledgement within 48hrs (Mon-Fri) contact the 2WW supervisor on 01438 285206
Luton & Dunstable
FAX: 01582 497910
FAX: 01582 497911
West Herts Hospitals
TEL: 01727 897199
Wherts-tr.twwreferrals@nhs.net
Colchester Hospital University FT twoweek.waitreferral@nhs.net
Mid Essex Hospitals FT
FAX: 012455 16751
Southend University Hospital FT
FAX: 01702 508174