Download Referral Form: Intermediate Level (GPSI) Minor Surgery Clinic

Referral Form: Intermediate Level (GPSI) Minor Surgery Clinic
Clinics held at: Cestria Health Centre, Whitehill Way, Chester le Street, DH2 3DJ.
Telephone 0191 3887771. Please note that the clinic can not provide patient transport.
ROUTINE: Fax this form to 0191 3871803 - URGENT: Please call 0191 3333824
Patient Details
Name ……………………………………………….
D.O.B …………………….......(must be >18y old)
NHS number ……………………………………….
Address …………………………………………….
……………………………………………………….
.............................................................................
Post Code ………………………………………….
Telephone ………………………………………….
Referring Professional
Name ……………………………………………….
Surgery Address …………………………………..
……………………………………………………….
……………………………………………………….
Post Code ………………PCT ...………………….
Date of Referral….…………………………………
Telephone ………………………………………….
Fax ………………………………………………….
Reason for referral
NOTE : This is a GPwSI intermediate level service. Complex or worrying cases, especially those where malignant /
premalignant pathology is suspected, or where a lesion is large or in a difficult anatomical site should be referred to
Dermatology or Plastic Surgery. Problems beyond the skill level available in the clinic will be returned to the referrer
a.s.a.p. via fax / phone / letter with suggestions for alternative management. Although the vast majority of cases will
receive a “one stop” service with surgery on the day, patients should not expect that this is the only possible outcome.
Please specify problem being referred (tick the relevant box):
Benign diseases of skin tissue or structures - large skin tag/polyp, cutaneous horn, naevus, hemangioma,
pyogenic granuloma, seborrhoeic keratosis, dermatofibroma, lipoma, chondrodermatitis nodularis helicis.
Cyst - of skin, scalp or eyelid (excision), ganglion or digital mucous cyst (aspiration), small oral mucocoele (curette)
Diagnostic - excision or punch biopsy (not suspected malignancy)
Foreign body - removal from skin (not subcutaneous)
Nail disorder - requiring nail resection / avulsion / ablation (consider Podiatry first - few cases need resection!)
Low risk BCC - see Nice Guidance. BCC referrals can only be accepted from a Consultant or GPSI in
Dermatology, or from a Consultant Plastic Surgeon
Please confirm the following MUST’s and MUST NOT’s (tick the 2 boxes to acknowledge):
MUST BE
MUST NOT BE
(EXCLUSIONS)
Requiring surgical treatment (ie non-surgical treatment has failed or is inappropriate)
Causing either: pain, loss of function, other significant problem, severe psychological distress
Unsuitable for “watch and wait” approach
Suitable for GPSI management (skill level NOT equivalent to Consultant Dermatology / Plastics)
A “2 week rule referral” condition, nor for diagnosis of any possible / suspected (pre)malignancy
Treatment proposed for simple cosmetic / aesthetic reasons
Extensive (>1-2cm) or in a difficult site (tight skin, lying over vulnerable structure eg tear duct etc)
Likely to require skin graft
On warfarin or have a significant bleeding or healing disorder
Moribund via overriding pathology, immunocompromised or have active infection in the lesion
Bowen’s disease, actinic keratosis, keratoacanthoma, viral wart or verruca, molluscum
contagiosum, port wine stain, xanthelasma, keloid, otherwise asymptomatic spider naevus
Relevant History (including size, site and working diagnosis)
Medication & Allergies ( ! )
(attach separate list if necessary)
Version 1 : Sept 2011
for office use: date received / appointment date