SOUTH WEST LONDON CANCER NETWORK
Suspected Children’s Cancers Referral Form (NICE 2006)
Date of GP decision to refer:
Urgent Referrals Criteria
(Please tick category)
GP DETAILS
CH 1 Abnormal blood count suggesting
further investigation

CH 2 Lymphadenopathy, if one or more of
the following are present (particularly in the
absence of local Infection:
 Lymph nodes are non-tender, firm or
hard
 Lymph nodes are greater than 2 cm in
size
 Lymph nodes are progressively
enlarging
 Other features of general ill health,
fever or weight loss
 Axillary node involvement (in absence
of local infection or dermatitis)
 Supra-clavicular node involvement

GP name and initials:
GP Practice Code:
Address:
Post Code:
Telephone No:
Fax. No:
PATIENT DETAILS
CH 3 Shortness of breath, in association of
the above signs, particularly if not responding
to bronchodilators

CH 4

Persistent parental anxiety
Last Name:
First Name:
Address:
Post Code:
Daytime Tel or Mobile:
Gender:
Date of Birth:
Age:
Interpreter required?
CH 5 Recurrent presentation (3 times or
more) with the same symptoms and no
diagnosis
No. of pages faxed:

Hospital No:
Y/N
Language:
M

F

Ethnicity:
NHS No:
COMMENTS/OTHER REASONS FOR URGENT REFERRAL
Patient Awareness Questions:
1. Has the parent / guardian or patient been made aware of the nature of their referral?
2. Has the patient / guardian or patient been supplied with supportive information
about the Urgent Suspected Cancer referral process?
3. Have you asked the patient / guardian or patient if they will be available
to attend an appointment within the next two weeks?
4. Has the patient / guardian or patient indicated to you that they
would be available to attend an appointment within the
next two weeks?
Yes  No 
Yes  No 
Yes  No 
Yes  No 
SOUTH WEST LONDON CANCER NETWORK
How to make urgent referrals for suspected children’s cancers
Please FAX this form to the Cancer Office at the relevant hospital, with or without an accompanying
letter. You should receive acknowledgement by fax that your referral has been received. Please
ensure that the referral reaches the hospital within 24 hours of the GP’s decision to refer.
Epsom and St Helier NHS Trust
Epsom and St Helier NHS Trust
Epsom General Hospital
Dorking Road, Epsom
Surrey KT18 7EG
St Helier Hospital
Wrythe Lane, Carshalton
Surrey SM5 1AA
FAX:
020 8296 2741
FAX:
020 8296 2741
TEL:
020 8296 2742
TEL:
020 8296 2742
Croydon Health Services NHS Trust
St George’s Healthcare NHS Trust
Croydon University Hospital
London Road, Croydon
Surrey CR7 7YE
St George’s Hospital
Blackshaw Road, Tooting
London SW17 0QT
FAX:
020 8401 3337
FAX:
020 8725 0778
TEL:
020 8401 3986
TEL:
020 8725 1111
E-mail: stgh-tr.CancerReferralOffice@nhs.net
FAX:
Kingston Hospital NHS Trust
St George’s Healthcare NHS Trust
Kingston Hospital
Galsworthy Road
Kingston KT2 7QB
Queen Mary’s Hospital
Roehampton Lane
London SW15 5PN
020 8934 3306
FAX:
020 8812 7937
TEL:
020 8934 3305
EMAIL: khn-tr.2WW@nhs.net
TEL:
020 8487 6037/6032
EMAIL: stgh-tr.CancerReferralOffice@nhs.net