Download Skin Cancer Referral Form

Suspected Malignant Melanoma/SCC Referral Form
PLEASE ENSURE PATIENT UNDERSTANDS NEED TO ATTEND WITHIN NEXT 2 WEEKS
Consultant:
Speciality:
GP Details
Patient Details
Name:
Address:
Tel No:
Fax Number:
Email:
Date of decision to refer:
Tel No (Home:
Tel No (Work):
Tel No (Mobile):
Hospital No:
DoB:
NHS No:
Age:
Gender:
Date of decision to refer:
Please provide the date(s) patient is unavailable within the next 2 weeks ……………………………….
Please make patient aware that if they are unavailable a delay in diagnosis could result. Therefore please ensure
that the patient understands the nature of the 2 WW appointment and the need for urgent attendance.
Does patient know cancer is suspected?
Yes
No
PLEASE DO NOT refer BCCs solar keratoses or Bowen’s disease on this form, it is for malignant melanoma or SCC only.
Please put a cross in one or more of the boxes below the suspected diagnosis:
Malignant melanoma
Squamous cell carcinoma
Multicoloured lesion
Raised or indurated crusty lesion with documented
increase in size
Asymmetrical/irregular borders
Eroded, fleshy lump
Raised or indurated crusty lesion 1cm in diameter
or more
Has the patient got a histologically diagnosed MM
Diagnosis confirmed on biopsy
Has the patient got a histologically diagnosed SCC
Diagnosis confirmed on biopsy
Change in shape/size/colour
Documented expansion over 2 months. Please
describe:
Change in sensation
Inflammation
Size (mm):
Site:
Duration:
If the patient does not present with any of the above symptoms refer to dermatology.
If any information is missing your patient will not meet the referral criteria for a two week appointment.
General history and other information
Risk Factors MM
Family History
Multiple Naevi
Atypical Naevi
Fair Skin/Poor Tanning
Excessive UV Exposure
Risk Factors SCC
Prolonged UV Exposure
Immunosuppression
Attachments:
Letter
Biopsy results
Results
Other
Past Medical History attached
Drugs History Attached
Date of Receipt:
Jun13
Skin Cancer
Patient Presents with
Pigmented lesions with:
 Major features:
- change in size
- irregular shape
- irregular colour
 Minor features:
- largest diameter 7mm or more
- inflammation
- oozing
- change in sensation
Major features 2 points, minor
features 1 point.
Suspicion is greater for 3 points or
more, but strong concerns about
any features should prompt referral.
Past history of
a transplant
and a new or
growing skin
lesion.
Non-healing lesions
larger than 1cm with
significant induration
on palpation,
commonly on face,
scalp or back of
hand with a
documented
expansion over 8
weeks.
Suspicion of
basal cell
carcinoma
(usually on
face)
Persistent or slowly
evolving
unresponsive skin
conditions in which
the diagnosis is
uncertain and cancer
is a possibility
Histological
diagnosis of
squamous cell
carcinoma
Urgent Referral
Referral to a
dermatologist
Non-urgent
referral
West Suffolk Hospitals Rapid Access Service
Your Doctor has referred you into the rapid access appointment service at the West Suffolk Hospital.
This service has been set up to ensure that, where possible, the Hospital will offer you an appointment within two weeks
of visiting your Doctor.
As the Hospital have a short time to arrange an appointment that is convenient for you, it is likely that they will contact
you by telephone within the next few days.
In order for this system to work, please can you ensure that your Doctor’s Surgery has an up to date daytime telephone
number for you, before you leave today.
If you do not have a telephone, or for any reason the Hospital are unable to contact you by telephone, please do not
worry. Your appointment will be posted to you.