One week wait suspected Cancer referral form

One week wait suspected Cancer referral form

To make a referral, complete the form below as completely as possible. Details will be stored on our server which only we can access, meaning it is not transmitted by e-mail. This will help to preserve patient confidentiality.

You may also fax/send an accompanying letter/ print out if you wish to do so. Any supplementary information should be included in this letter. Alternatively this form can be downloaded here, and then printed off and sent to us or faxed. It is important to try and include all reports of relevant scans as requested, and we will need to see the original scans prior to consideration of any treatment. The patient may bring them with them to their appointment. Cambridge Urology Partnership will contact the patient and make an appointment.

Download a copy of the one week wait form

You may also fax / send an accompanying letter/ print out if you wish to do so. Any supplementary information should be included in this letter.

Fields marked with * are mandatory

The Patient:

Surname*:
First name*:
Address*:
Date of birth*:
Male / Female*:
 Male Female
Email*:
Home telephone number:
Work telephone number:
Mobile telephone number*:
Does the patient have a previous urological history?:
 Yes No
Medical history:
Medication:
Does the patient take aspirin / clopidogrel / warfarin?:
 Yes No
Details:
Allergies:
 Yes No
Details:

Referral information (please complete)

Macroscopic Haematuria:
 Yes No

Persistent / Recurrent UTI, with haematuria >40 yrs:
 Yes No

Proven Microscopic Haematuria age>40 years:
 Yes No

A high PSA in men with clinically malignant prostate or bone pain, or unexplained urological symptoms:
 Yes No

PSA value and date of PSA test:
Asymptomatic with age specific raised PSA in men:
 Yes No

Previous PSA results with dates:
Palpable renal masses or suspicious renal masses on radiological imaging:
 Yes No
Swelling in the body of the testis suspicious of cancer:
 Yes No
Suspected penile cancer:
 Yes No
State any examination findings:

The Referring GP:

Name*:
Email*:
GP signature*:
Address:
Telephone no*:
Fax No:
Security Code*: captcha
Verify your submission by entering the security code: