Download Malignant soft tissue tumour referral form

URGENT SUSPECTED CANCER REFERRAL FORM
SUSPECTED MALIGNANT SOFT TISSUE TUMOUR IN ADULTS
Sarcoma Diagnostic Clinic
Patient Details
Full Name:
Other Names:
Sex:
Date of Birth:
NHS No.:
Hospital No.:
Interpreter Required?
Transport required?
Address:
Yes
Yes
 /No 
 /No 
Home Phone No.:
Mobile Phone No.:
Work Phone No.:
Preferred Phone
No.:
Email Address:
* N.B. It is essential that you provide a current contact telephone number for the patient so that
the Health Board can contact the patient within 24-hours to arrange a convenient appointment.
Practice Details
Referring GP:
Registered GP:
GMC Code:
Practice Name &
Address:
Practice Code:
LHB Code:
Tel No:
Date seen by GP:
Fax No:
Decision to refer date:
7A3
SOFT TISSUE SARCOMAS
Please refer patients to your local Sarcoma Diagnostic Clinic if one or more of the following symptoms
apply. There is a palpable lump that is ANY of the following:
Greater than 5cm in diameter (a golf ball is about 4.2 cm)
Yes  /No 
Deep to fascia, fixed or immobile
Yes  /No 
 /No 
Yes  /No 
Increasing in size rapidly
Yes
Painful
Clinical details regarding the suspicious lump (inc. location of lump):
Patient with suspected recurrence after previous resection should be referred to the Sarcoma Treatment
Centre via fax to 01792 703875
NB: Patients with the following should be referred to the more appropriate specialist team for an urgent
outpatient appointment using the Urgent Suspected Cancer Referral (USCR) form for that speciality:
 Any patient with a neck lump that persists for more than three weeks to the local Head & Neck Team
 Any patient with generalised lymphadenopathy or neck lumps with a lymphocytosis to the local
Haematology Team
Details of ABMU Health Board Soft Tissue Sarcoma diagnostic Clinics
Please either:
 Fax to 01792 703875
 Or attach to generic e-referral template and send to Plastic Surgery in Morriston Hospital as an USC
referral
Is the patient aware of the reason & urgency for referral & aware that they will be offered an
appointment within 10 working days?
Yes  /No 
Name of referrer (please print):
Signature:
Date:
………………..................................
Soft Tissue Sarcoma Referral Form October 2011
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