Gloucestershire Hospitals NHS Foundation Trust: Fax 08454 222564
Suspected Head and Neck Cancer 2 Week Wait Referral
Please use this form for all suspected head and neck (incl. thyroid) cancer referrals, attaching an accompanying
letter where appropriate (Please do not delay in sending the referral, the letter can be sent at a later date) and
fax immediately to the above number. The original cover sheet and letter should be retained by the referring
practice. Please do not send the original copy to the booking centre as this may cause duplication.
Name of Referral Doctor
GP Code
Address
Date of Decision to Refer
Registered GP
GP Code
Telephone Number
Fax Number
PCT Code
Postcode
Previous Surname
Age
NHS Number
Has patient previously
visited this hospital?
Hospital number (if known)
Patient Name
Date of Birth
Sex (M/F)
Patient Tel No: Home
Mobile
Work
Special Requirements
Referral information
Cancer area suspected:
Referred to:
Oral cavity 
ENT

Larynx

Pharynx 
Thyroid 
Neck lump 

Maxillofacial
Have you told the patient the reason for referral?
Y N
Immediate Referral: patients with tracheal compression including stridor due to thyroid swelling
Urgent Referral
Hoarseness > 3 weeks
Stridor
Swelling in parotid / submandibular gland
Persistent red & white patches of the oral
mucosa (painful/swollen/bleeding)
Unexplained tooth mobility > 3 weeks
Unexplained persistent sore throat
Progressive mouth, throat ulceration
Persistent oral swelling/ulceration (>3 weeks)
Unilateral, unexplained pain in head and neck
> 4 weeks, associated with Otalgia and
normal otoscopy
Thyroid: a thyroid swelling associated with any of the following:
A solitary nodule increasing in size
Unexplained hoarseness or voice changes
A history of neck irradiation
Very young (pre-pubertal) patient
A family history of an endocrine tumour
Patient aged 65 years and older
Comments
(additional info)
Hospital Office Use Only
Date received:
Appointment date:
Malignant: Y/N
DH: 04/2007