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:
FORENAME1 SURNAME
Date of Birth: DOB
Gender:
GENDER
Address:
HOUSENAME ADDRESS1
Email Address:
Tel (Daytime): TELNUMBER
Tel (Work):
WORKPHONE
Tel (Mobile):
NHS No:
NHSNUMBER
Hospital No:
HOSPNUMBER
Ethnicity:
First Language:
ADDRESS2
ADDRESS3
ADDRESS4
POSTCODE
Interpreter Required?
GP Details
GP Name:
Address:
RESGP
SITETITLE
SITENAME
SITEADD2
SITEADD3
SITEADD4
SITEPOSTCODE
Referring Dentist Details
Dentist Name:
Dental Practice:
Address:
Tel No:
Fax No:
PRACTISEPHONE
Date of referral: DATE:FULL
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
1 of 3
iSoft Synergy v0.4
Oral Cavity
Pharynx
Larynx
Post Nasal Space
FORENAME1
SURNAME
RBFT FAX Number 01183226698
Symptoms-unexplained
Persistent hoarseness 6 weeks, or longer:
Pain on swallowing over 3 weeks:
Weight loss with Hoarse > 3 weeks and normal CXR
Dysphagia > 3 weeks:
Unilateral sore throat
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
Allergies
[SENSITIVITY]
Current Medication:
_repeatmed2
_repeatmed3
_repeatmed4
_repeatmed5
[CURTREATMENT]
Other Relevant Medical History: [CURPROBLEMS]
Additional Information
Additional reasons for requesting this referral:
2 of 3
iSoft Synergy v0.4
FORENAME1
SURNAME
RBFT FAX Number 01183226698
Please state if you are attaching a letter / computer printout
with this information:
Yes
No
Is the patient on an anti-coagulant?
Yes
No
Is the Patient available for an appointment
within the next 14 days:
Yes
No
Has the nature of this urgent referral been
discussed with, and the urgent two week
wait referral leaflet given to, the patient:
Yes
No
1st OPA Required by:
62 Day Breach Date:
3 of 3
iSoft Synergy v0.4
RBFT FAX Number 01183226698
FORENAME1
SURNAME