Suspected Testes/Penis Cancer Referral Form
PLEASE ENSURE PATIENT UNDERSTANDS NEED TO ATTEND WITHIN NEXT 2 WEEKS
GP Details
Patient Details
GP Name:
Name:
Practice Name:
Address
Address:
Postcode:
Postcode:
Daytime Tel No:
Tel No:
Date of Birth:
Fax No:
Hospital No:
PCT Code:
NHS No:
Date of Referral ……………
Please provide the date(s) patient is unavailable within the next 2 weeks ……………………………….
Please make patient aware that if they are unavailable a delay in diagnosis could result. Therefore please ensure
that the patient understands the nature of the 2 WW appointment and the need for urgent attendance.
Does patient know cancer is suspected?
Yes
No
Please tick the appropriate box(s) below
Urgently Refer Patient for:
Tick
Swelling or mass in the body of the testis (consider urgent Ultrasound if the
mass does not transilluminate and/or when the body of the testis cannot be
distinguished)
Age Range
Any age
(Risk age range 20 – 40)
Penile cancer – concerns regarding progressive ulceration or a mass in the
glands or prepuce, can involve the skin of the penile shaft.
Other relevant information/investigations performed/results:
If you wish to send an accompanying letter please do so.
Date of Receipt:
For Hospital Use Only:
Event
Date
Outcome
Date of appointment offered
Patient to be seen by
If cancer patient to be treated by
Jun 13
West Suffolk Hospitals Rapid Access Service
Your Doctor has referred you into the rapid access appointment service at the West Suffolk Hospital.
This service has been set up to ensure that, the Hospital will offer you an appointment within two weeks of visiting
your Doctor.
As the Hospital have a short time to arrange an appointment that is convenient for you, it is likely that they will
contact you by telephone within the next few days.
In order for this system to work, please can you ensure that your Doctor’s Surgery has an up to date daytime
telephone number for you before you leave today.