LOWER GI – 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
GP’s DETAILS
Surname
First name(s)
Address
GP’s name
Surgery name
Surgery address
Date of birth
Home telephone:
Mobile/Work telephone:
NHS number:
Hospital number:
Surgery telephone:
Surgery fax:
URGENT TWR REFERRAL CRITERIA
ANY AGE
TICK
OVER 60 YEARS OF AGE
TICK
Rectal bleeding WITH change in bowel habit
Rectal bleeding persistently WITHOUT anal
to looser stools and/or increased frequency
symptoms (anal symptoms include: soreness,
of defecation PERSISTENT for 6 WEEKS
discomfort, itching, lumps and prolapse, as
well as pain)
CONFIRMED iron deficiency anaemia
Change in bowel habit to looser stools
WITHOUT obvious cause.
and/or increased frequency of defecation,
Criteria for iron deficiency requiring
WITHOUT rectal bleeding and PERSISTENT for
investigation:
6 WEEKS
o Hb Male < 13.5 Female < 11.0
o Ferritin < 15
Definite palpable right-sided abdominal mass
Why would this patient NOT be suitable for a ‘straight
to test’ colonoscopy?
Definite palpable right-sided rectal mass
Please indicate if the patient has any of the following:
Insulin dependent diabetes
Warfarin
Non-insulin dependent diabetes
Clopiodgrel
Prosthetic valve
DVT/PE within 3/12
Previous endocarditis
AF with systemic embolous OR mitral stenosis
RENAL FUNCTION – PLEASE ENSURE THAT ONE OF THE TWO BOXES IS COMPLETED
PLEASE NOTE THAT THE REFERRAL WILL NOT BE ACCEPTED WITHOUT THIS INFORMATION
eGFR in the last 2 months ________ mL/min
If no eGFR within last 2 months, please arrange
Date:
bloods to be taken prior to referral.
Date of blood test:
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:
GP signature
TO MAKE A REFERRAL TO FRIMLEY PARK HOSPITAL, fax this form and any additional correspondence to:
01276 604506