Appendix 1
The Leeds Teaching Hospitals NHS Trust
ORAL CANCERS REFERRAL FORM
URGENT (WITHIN 14 DAYS) APPOINTMENT REQUEST
Referral to the Oral Oncology Clinic Leeds Dental Institute
FAX: 0113 206 4508 or PHONE: 0113 206 5141
Please do not use this pro-forma if your patient does not have symptoms as defined in the
NICE 2005 Referral Guidelines for Suspected Cancer
Patient
Title
First Name
Surname
Referrer
GP Name
Address
GP Telephone
Number
GP Address
Postcode
GP Fax Number
Date of Birth
GDP Name
Gender
GDP Telephone
Number
GDP Address
Age
Telephone (Home)
Telephone (Work)
Telephone (Mobile)
NHS Number
E-mail address
(please print)
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Is an interpreter
Yes 
No 
required?
If so which
language?
If transport is required GP must arrange
transport for first visit.
Date of Decision
to Refer
Date of Referral
Referral Information (please tick box)
1.
Ulceration of oral mucosa persisting for > 3 weeks

2.
Oral swellings persisting for > 3 weeks

3.
All red or white patches of the oral mucosa

4.
Unexplained tooth mobility not associated with periodontal disease

5.
Radiographic evidence of osteolytic lesions

6.
Unresolved neck masses for > 3 weeks

A. Is the patient aware of the possible diagnosis of cancer?
Y/N
B. Has a 2 week wait patient information leaflet been given?
Y/N
C. Is the patient available and willing to attend an appointment within the next 14 days?
Y/N
If not, refer when willing and able to attend.
Any other relevant information? (feel free to add an accompanying letter)
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