HOSPITAL NAME
Thames Valley
Cancer Network
2 Week Wait Referral for Suspected Head and Neck Cancer
(Including Thyroid)
Please attach to the Choose and Book Unique Booking Reference Number (UBRN) within 24 hours
Referral Receipt Date:
Patient Details
Name: «PATIENT_Forename1» «PATIENT_Surname»
Email Address:
First Language:
Address:
«PATIENT_BlockAddress»
GP Details
GP Name:
Address:
«REFERRAL_Clinician»
«PRACTICE_Name»
«PRACTICE_BlockAddress»
Referring Dentist Details
Dentist Name:
Dental Practice:
Address:
Date of Birth: «PATIENT_Date_of_Birth»
Gender:
«PATIENT_Sex»
Ethnicity:
Interpreter Required:
Tel (Daytime): «PATIENT_Main_Comm_No»
Tel (Work):
Tel (Mobile):
NHS No:
«PATIENT_Current_NHS_Number»
Hospital No:
Tel No:
«PRACTICE_Main_Comm_No»
Fax No:
Date of referral: «SYSTEM_Date»
Date Referral Received:
Tel No:
Fax No:
Your patient will be seen under the 2 week rule if one or more of the following criteria are present.
Please tick the appropriate box(es) and add relevant details below.
Cancer Area suspected
Salivary Gland
Thyroid
Neck
Sinus Nasal
Oral Cavity
Pharynx
Larynx
Post Nasal Space
Symptoms-unexplained
Persistent hoarseness 6 weeks, or longer:
Pain on swallowing over 3 weeks:
Dysphagia > 3 weeks:
Weight loss with Hoarse > 3 weeks and normal CXR
Unilateral sore throat
Page 1 of 3 Vision v.0.8
«PATIENT_Forename1» «PATIENT_Surname» «PATIENT_Current_NHS_Number»
Please Fax to Hospital Fax Number 01183226698
Thyroid swelling associated with
A solitary nodule increasing in size
A history of neck irradiation
A family history of an endocrine tumour
Unexplained hoarseness or voice changes
Children and teenagers
Patient 65 years or older
Cervical lymphadenopathy
Clinical Examination
Lump in neck > 4 weeks
Oral ulceration/tumour > 4 weeks
Unilateral Otalgia with a normal otoscopy
Non - healing tooth extraction sockets/unexplained loosening of teeth
Orbital mass
Tonsillar enlargement/ulceration
Cranial neuropathy – e.g.
Weakness in presence of parotid lump
Unexplained red/white patches oral mucosa or
lichen planus which are painful, swollen or bleeding
Other - please state
Risk Factors
Amount smoked
Alcohol consumed – amount
Mandatory - A recent (within 3 months) renal function measurement must be included to prevent any delays with
contrast CT scanning.
If you do not have this information please give the patient a bloods form for U&Es at referral
eGFR value:
Date :
Additional Information
Please state if you are attaching a letter / computer printout / CD with this information:
YES
NO
Other Relevant Information
Allergies
«DRUG_ALLERGY»
Current Medication:
«REPEATS»
Other Relevant Medical History:
Additional Information
Additional reasons for requesting this referral:
Is the patient on an anti-coagulant?
Yes
No
Please state if you are attaching a letter / computer printout with this information: Yes
No
Is the Patient available for an appointment within the next 14 days:
No
Yes
Page 2 of 3 Vision v.0.8
«PATIENT_Forename1» «PATIENT_Surname» «PATIENT_Current_NHS_Number»
Please Fax to Hospital Fax Number 01183226698
Has the nature of this urgent referral been discussed with, and the
urgent two week wait referral leaflet given to, the patient:
Yes
1st OPA Required by:
62 Day Breach Date:
Page 3 of 3
Vision_v.2 – RBFT
No
«PATIENT_Forename1» «PATIENT_Surname» «PATIENT_Current_NHS_Number»