MINOR SURGERY – DES- REFERRAL FORM
The patient’s
Surname
……………………………………………………………………….
Practice stamp
Forename
……………………………………………………………………….
Address
……………………………………………………………………….
…………………………………………………………………………………………………………………………………………..
NHS number ………………………………………………… DOB………………………………………………………………..
Home telephone ……………………………………………… Mobile ………………………………………………….
E mail address …………………………………………………………………………………………………………………..
Referring doctor’s name…………………………………………….........................................................
Surgery telephone……………………………………… surgery fax …………………………………………………
Surgery e mail address……………………………………………………………………………………………………….
PLEASE READ THE FOLLOWING FOR GIUDANCE ON LESIONS THAT CAN BE
DONE AT ALEXANDRA SURGERY as stipulated by NHS ENGLAND
1) Injections (muscles, tendons and joints) and aspirations
2) Invasive procedures, including incisions and excisions.
Group (1) includes treatment of the following:
 Capsulitis
 Bursitis
 Tendinitis
 Tenosynovitis
 Compression
 Aspiration indications: diagnostic or therapeutic and where such treatment will be likely to
improve clinical outcomes
Group (2) includes:
 Pigmented and vascular legions where histology is required (excluding suspected
melanomas)
 Lesions with atypical behaviour such as bleed or change in colour, where histology is required.
These might include, for example, papilloma, dermatofibroma or seborrhoeic keratosis.
 Lesions that are symptomatic and/or have been inflamed on more than one occasion at
the time of consultation
 Epidermoid cysts that are symptomatic and/or have been inflamed on more than one
occasion at the time of consultation
 Keratoacanthoma
 Toes with chronic or recurrent in-growing nails or nail deformity requiring surgical removal of
part or the entire nail along with nail bed ablation where appropriate.
 Surgical drainage of abscesses and haematomas where this is deemed best treatment
 Removal of foreign bodies only where local anaesthetic and incision is required as part of
procedure

Low-risk Basel Cell Carcinomas (BCCs), as defined in current Nice Guidance on Cancer
Services1. For BCCs which do not meet the low-risk criteria or where there is any
diagnostic doubt a referral should be made as per NICE guidelines
Please provide the following in the space provided below
 Description of the lesion, Duration
 risk factors - recurrent infections, itching, bleeding, rapid
change in shape and size, change in colour ,unusual hair
growth etc. ect
 Other significant issues associated with the referral.
 Is the patient on anticoagulation therapy? yes
no
 If they are on anticoagulation therapy they must stop the
tablets for anticoagulation, three days before the surgery.
Please inform the patient that the procedure will be, mostly, carried out on the day of the consultation
with the surgeon.
Provisional DIAGNOSIS ………………………………………………………………………………………………
Signature of referring doctor ………………………………………………………………………..…
Date …………………………………………………………………………………………………………….….
Fax: Alexandra surgery - 0208 888 3815
E mail: alexandrasurgery@nhs.net - tel: 0208 888 2518
1
NICE Guidance on cancer services: Improving Outcomes for People with Skin Tumours including Melanoma (update): The
Management of Low-risk Basal Cell Carcinomas in the Community (May 2010)