Download visible and non visible

Referral for One Stop (visible and non visible) Haematuria Clinic
For Suspected Cancer (2 Week Rule)
THE PATIENT HAS CONFIRMED THAT THEY WILL BE AVAILABLE WITHIN THE NEXT TWO WEEKS
Patient Details:
Name
Address
Tel No:
NHS No:
DOB:
Translator Reqd
GP Details:
Name
Surgery Address
Tel No:
Fax No:
Date
Specify Language
Patient informed of possible cancer diagnosis?
Yes
No
INCLUSION CRITERIA (please select)
Previously UNINVESTIGATED SIGNIFICANT (visible and non-visible) haematuria
as per BAUS guideline/local Joint Formulary and Referral Guidelines pathway
Patient shows no infection on MSU before referral
MSU has been undertaken
PLEASE SEND THE FOLLOWING FOR ALL PATIENTS
All boxes must be ticked to ensure that the results will be available for review in clinic. MSU must have been reviewed
by GP prior to referral and any infection treated:
MSU
U&Es
FBC
PSA (male patients only)
THIS REFERRAL WILL ACCESS THE FOLLOWING ON THE SAME DAY:
Renal Ultrasound, Urology Consultation and Flexible Cystoscopy
OTHER PROBLEMS (please select)
Diabetes
Oral Rx
Insulin
Cardiac
Prosthetic valve
Warfarin*
Respiratory
COPD
Asthma
* If on warfarin please state indication:
Comments:
GP Signature:
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
Version 3/Dec 14