Urology referral form - Nwlcn.nhs.uk

NORTH WEST LONDON CANCER NETWORK
URGENT SUSPECTED CANCER REFERRAL FORM (UROLOGY)
To make a referral, FAX this form to the Urgent Referral Team at the relevant hospital (see overleaf). If you
wish to send an accompanying letter, please do so. All referrals must be FAXED.
Hospital to which patient is being referred:
Patient details
NHS number:
Surname:
GP Details
Dr:
Address:
First Name:
Age / D.O.B:
Address:
Tel:
Email:
Date of decision to refer:
Postcode:
Tel day: Tel eve: Signature:
Have you informed the patient that you suspect a urology cancer Y / N
Have you told the patient they will be seen within 2 weeks
Y / N
Has the patient had a previous diagnosis of cancer Y / N (Specify if known)
Has the patient previously visited this hospital Y / N
Hospital number (if known):
First language:
Interpreter required Y / N
Prostate
(please tick as appropriate)
Either
Or
Renal
hard, irregular prostate on digital rectal examination (DRE)
raised / rising age specific PSA with clinically malignant prostate or bone pain, or unexplained urological
symptoms
asymptomatic with age specific raised PSA in men (50 yrs with recurrent / persistent UTI and haematuria
patient >50 yrs with unexplained microscopic haematuria >2+ on >2 occasions (attach MSU result)
Testicular
swelling within the body of the testes (not varicocele / epid cysts) Ultrasound Y / N Date:
Penile
progressive ulceration
lump / mass
One tick within each category = urgent referral
Source: NICE guidelines for suspected urological cancer
Information given to patient:
Additional Clinical Information: Include any investigations arranged or results obtained, and any other information you
think relevant.
Continue on a separate sheet if necessary ensuring patient details and referring doctor’s name are on additional sheets
Please ensure this form is received in the Trust within 24 hours of GP decision to refer

North West London
Hospitals NHS Trust
Fax: 020 8235 4188
Tel: 020 8235 4293
Ealing Hospital NHS
Trust
Fax: 020 8967 5005
Tel: 020 8967 5000, x3921
Imperial College Healthcare
NHS Trust
Charing Cross Hospital
Fax: 020 8846 7564
Tel: 020 8383 5000
St Mary’s Hospital
Fax: 020 7886 1580
Tel: 020 7886 1527
Hillingdon Hospital NHS Trust
Fax: 01895 279890
Tel: 01895 279698
2WW dedicated fax line : 01895
279807
Chelsea and Westminster
NHS Foundation Trust
Fax: 020 8746 8814
Tel: 020 8237 2679
West Middlesex
University Hospital NHS
Trust
Fax: 020 8321 5157
Tel: 020 8321 6776
Please ensure this form is received in the Trust within 24 hours of GP decision to refer