Hospital Reference Code: XSXSX
2 Week Urgent Referral for Suspected Haematology Cancer
To make a referral, FAX this form to the Suspected Cancer Referral Team on 01753 849200
Please note that this form will be audited for completeness
Patient Details
Surname
:
Forenam
e:
Address:
Date of Birth:
Gender:
Ethnicity:
NHS Number:
Hospital Number:
Please select number(s) for use in the next 24 hours:
Home Telephone:
Work Telephone:
First Language:
Interpreter
Required
X
Is the patient aware this is
a suspected cancer
referral?
Is the patient available for
an appointment within the
next 14 days?
Mobile Telephone:
Is the patient available for
for 62 days from date of
referral?
Has the patient been given
a 2 week wait leaflet?
Other (relative/next of kin):
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
GP Details
GP Name:
«PATIENT_County»
Telephone Number:
«PRACTICE_Main_Comm_No»
Address:
«PRACTICE_Name»
«PRACTICE_BlockAddress»
Fax Number:
Date of Referral:
Date Referral
Received:
«PRACTICE_Fax_No»
«SYSTEM_Date»
Suspected Diagnosis:
Leukaemia:
Lymphoma (HD or NHL):
Myeloma:
Weight loss:
Fatigue:
Itching:
Breathlessness:
Night sweats
Bruising
Recurrent infections
Bone pain:
Symptoms:
Clinical examination:
- neck
Lymph nodes:
- axilla
- groin
- other
Investigations: (full blood count is essential):
Investigations done:
Chest X-Ray
Where carried out:
Hospital
Phone No. if not HWPH
Hepatomegaly
Splenomegaly
Bruising / petechiae
Full Blood Count
Hospital
Please state if you are attaching a letter / computer printout with this information (please
telephone the GP referrer if extra information is required):
Mobile number of referring GP if appropriate:
Is the patient on anti-coagulant or anti-platelet medication?
«REPEATS»
«DRUG_ALLERGY»
Additional Information
Yes
No
Yes
No