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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.