• Referral form for patients for consideration of robotic radical prostatectomy.  Download
• Referral form for patients with suspected urological cancer.  Download

Please complete information about your patient if you would like them to be seen for consideration for a radical prostatectomy by filling out the form below.

Date of Referral:

The Patient:
* Surname:
* First Name :
Address:
* DOB:
Telephone No. :
Work No :
* Mobile No :
* E-mail :
Does the Patients have a previous urological history?:	yes No
Medical History :
Medication:
Does the Patients take aspirin / clopidogrel / warfarin:	yes No
Allergies:	yes No
Body mass index (BMI)
Information about patient's prostate cancer:
Date of diagnosis?:
where was the cancer diagnosed?:
The PSA at diagnosis?:
The most recent PSA?:
Date:
Prostate volume on transrectal ultrasound (if known):
Gleason Grade (If known):
No of involved cores (IF known):
T stage of tumour (If known):
Have you had any of the following investigations?:
If so, please state the date and provide the report on a separate sheet:
MRI?:
CT?:
Bone Scan?:
Have you had any other treatment for prostate cancer including hormonal treatment?:
Your GP:
* Name:
Address:
* Telephone No:
Fax No:
Your Urologist:
* Name:
Address:
* Telephone No:
Fax No:
* Security Code: