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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