Surrey, West Sussex and Hampshire
Cancer Network
Head & Neck, including Thyroid – Suspected Cancer - TWR Referral Form
Please fax this form within 24 hours of seeing the patient for hospital appointment within 14 days
Patient Details
GP Details
Name:
GP Name:
Address:
Address:
DOB:
Home :
Surgery :
Mob/Work:
Surgery Fax:
Hospital No:
tEL:
NHS No:
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Urgent Referral Criteria
Suspected
Site
Mouth incl
Lip
Throat
Neck Lump
incl LN
Salivary
Glands
Thyroid
Other
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Possible Head and Neck Cancer
Unexplained lump in neck of recent onset or an existing lump changing in size in last 3-6 weeks
Unexplained persistent swelling in parotid or submandibular gland
Unexplained persistent sore or painful throat with or without dysphagia
Unilateral unexplained head/neck pain for more than 4 weeks, with otalgia but normal otoscopy
Unexplained ulceration or mass of oral mucosa persisting for more than 3 weeks
Unexplained red and white patches of the oral mucosa that is painful or swollen or bleeding.
Hoarseness for more than 6 weeks
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Possible Thyroid Cancer
Patients with symptoms of tracheal compression, including stridor due to thyroid swelling: ADMIT IMMEDIATELY
Solitary Thyroid Nodule getting larger
Thyroid swelling & unexplained hoarseness
Thyroid swelling and Hx neck irradiation
Thyroid swelling & cervical lymphadenopathy
Thyroid swelling and FHx endocrine tumour
Thyroid swelling pre-puberty or aged > 65 yrs
Additional mandatory clinical information required
Please attach summary of Past Medical History, Medication, and Allergies.
I have told this patient I am referring them under the TWR and have explained this process to them.
Referral Date:
GP Signature:
4
To make a referral FAX form to relevant Trust
Ashford Hospital
Frimley Park Hospital
Royal Surrey County Hospital
Fax Number
0800 923 4668
01276 604506
01483 464848
St Peter’s Hospital
0800 923 4668
Surrey & Sussex Healthcare Trust
Admin Comments:
01737 231733
Surrey, West Sussex and Hampshire Cancer Network E HN RF v1
Hospital admin only:
Date referral received:
Date faxback to GP:
st
Date 1 appt:
Referral within guidelines?