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Referral for One Stop (visible and non visible) Haematuria Clinic For Suspected Cancer (2 Week Rule) THE PATIENT HAS CONFIRMED THAT THEY WILL BE AVAILABLE WITHIN THE NEXT TWO WEEKS Patient Details: Name Address Tel No: NHS No: DOB: Translator Reqd GP Details: Name Surgery Address Tel No: Fax No: Date Specify Language Patient informed of possible cancer diagnosis? Yes No INCLUSION CRITERIA (please select) Previously UNINVESTIGATED SIGNIFICANT (visible and non-visible) haematuria as per BAUS guideline/local Joint Formulary and Referral Guidelines pathway Patient shows no infection on MSU before referral MSU has been undertaken PLEASE SEND THE FOLLOWING FOR ALL PATIENTS All boxes must be ticked to ensure that the results will be available for review in clinic. MSU must have been reviewed by GP prior to referral and any infection treated: MSU U&Es FBC PSA (male patients only) THIS REFERRAL WILL ACCESS THE FOLLOWING ON THE SAME DAY: Renal Ultrasound, Urology Consultation and Flexible Cystoscopy OTHER PROBLEMS (please select) Diabetes Oral Rx Insulin Cardiac Prosthetic valve Warfarin* Respiratory COPD Asthma * If on warfarin please state indication: Comments: GP Signature: 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 Version 3/Dec 14