RENAL CANCER MDT DIRECT REFERRAL FORM TO LTHT
Date of MDT:
Name of referring consultant:
Hospital: Please select your hospital
Patient Details/ Addressograph:
Surname:
First Name:
Date of Birth:
Address:
NHS Number:
Patient Contact Number:
GP. Name:
GP Phone No:
Family history of renal cancer
Yes
No
History of diabetes
Yes
No
History of hypertension
Yes
No
History of any renal disease
Yes
No
History of renal surgery
Yes
No
Symptoms – loin pain
Yes
No
Symptoms – haematuria
Yes
No
Symptoms – incidental
Yes
No
Any other co-morbidities
Examination findings
U&E
Cr
eGFR
Ca
LFT
Patient’s wishes
Imaging to be sent (to be reviewed in specialist MDT):
Yes
If YES
Ultrasound
CT
Chest X-ray
MRI
DMSA
Bone scan
No
MDT provisional plan: Surgery
Curative intent
Diagnostic surgical procedure only
Oncology
BSC
Comment:
62 Day Breach Date:
Key Worker/CNS Name:
Details of Person Competing Form:
Name:
Role:
Date:
Attach this electronic form to the PPM documents tab
Version 1 (Wednesday, 14 December 2011)