Download THE PATIENT HAS CONFIRMED THAT THEY WILL BE AVAILABLE

THE PATIENT HAS CONFIRMED THAT THEY WILL BE AVAILABLE WITHIN THE NEXT TWO WEEKS
URGENT TWO WEEK REFERRAL FOR SUSPECTED UROLOGICAL CANCER
If Patient does not fulfil the criteria, please consider urgent/routine referral or treat/watch and wait approach
PATIENT DETAILS:
Surname
Forename(s)
DOB/Age
Male/Female
NHS No
Address
Postcode
Telephone Preferred
GP DETAILS:
Name
Practice Code
Telephone
Fax
Practice Name
Practice Address
Practice Postcode
Date of Decision to
Refer
Telephone Home
Translator Required
Telephone Mobile
Specify Language
Does the patient have a learning disability: Yes
No
Is the patient aware of a possible cancer diagnosis: Yes
No
PROSTATE CANCER- Urinary TRACT infection must be excluded before PSA testing.
Please send a formal MSU in symptomatic men.
Hard irregular prostate on digital rectal examination (DRE)
Raised/rising age specific PSA
ng/ml (1st test)
ng/ml (2nd test after 1-3 months if the
is borderline)
1sttest
Clinical suspicion of metastatic prostate cancer
RENAL CANCER
Abdominalmass arising from urinary tract felt to be renal or imaging shows renal mass (not cyst)
If confirmed by imaging, please attach report.
BLADDER / UROTHELIAL CANCER–
PLEASE NOTE: PATIENTS WITH PREVIOUSLY UNIVESTIGATED SIGNIFICANT (visible or non-visible)
HAEMATURIA MUST BE REFERRED TO THE 2WW ONE STOP HAEMATURIA CLINIC USING THE
APPROPRIATE REFERRAL FORM.
Patient > 40 yrs with recurrent/persistent UTI and haematuria
Clinical suspicion /imaging showing mass arising from bladder
TESTICULAR CANCER: Swelling within the body of the Testis
PENILE CANCER:
progressive ulceration or lump/mass
Additional clinical information including drug history: (please attach clinical summary if available)
PLEASE REFER VIA CHOOSE AND BOOK. IF NO APPOINTMENTS AVAILABLE, CLICK “DEFER TO PROVIDER”.
Do not send hard copy as well as C&B. In case of problems telephone: 01271 370214
Confirmation of referral receipt and appointment details will be sent to referring GP