guidelines for the management of urological cancer - Merseyside ...

Appendix 2 – Referral Form
Referring GP
Registered GP
GP Address &
postcode
GP Tel. No.
GP Fax. No.
Date seen by GP:
SUSPECTED UROLOGICAL CANCER – REFERRAL FORM
To make an URGENT REFERRAL, Fax / E-mail to:
Telephone Contact No.:
REFERRER’S DETAILS
GP Code:
Decision to refer date:
Urology
PATIENT DETAILS
Title & Surname
Forename(s)
D.O.B. AGE: Gender: Male Female
Address
Postcode *Tel. No. (day) Mobile Tel.
*Tel. No. (evening) NHS No. Hospital No.
* N.B. It is essential that you provide a current contact telephone number for the patient so that the Trust
can contact the patient within 24-hours to arrange a convenient appointment.
CULTURAL, MOBILITY, IMPAIRMENT ISSUES
What is the patient’s preferred first language? ………………………………………………..
Does the patient require Translation or Interpretation Services? YES NO ………………………………………
Please list any hearing or visual impairments requiring specialist help (Sign language, Braille, Loop Induction systems)
………………………………………………………………………………………………………
Is Disabled Access Required? YES NO Is transport required? YES NO
………………………
Ethnic Origin: ……………………………………….. Religion: ………………………………………………………
Is the patient from overseas? YES NO Is the patient a temporary visitor? YES NO
REFERRAL INFORMATION (referral guidelines are provided below / attached to proforma)
PROSTATE
Hard irregular prostate on DRE
YES NO
PSA Value ………..ng/ml
symptoms (including symptoms of metastases) and raised PSA
Raised age-related PSA
Age related cut-off measurements: 50-59 >3.0ng/ml; 60-69 >4.0ng/ml;
70-80 >5.0ng/ml. Elderly patients or those with significant co-morbidity
do not require urgent referral for mildly elevated PSA in the absence of
symptoms. Exclude urinary infection before PSA testing.
YES NO
YES NO
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