Suspected head and neck cancer 2 week wait referral Date of decision to refer: Date referral received at Trust: Surname: First Name: Title: Gender: DOB: / / NHS Number: Ethnicity: Language: Interpreter required: Transport required: Patient Address: Postcode: Contact numbers: Home: Mobile: Email: Usual GP Name: Practice Name : Practice Address: Practice Code: Direct line to the practice (Bypass) : Main: Fax: Email: Referring Clinician: IMMEDIATE ADMISSION TO EMERGENCY DEPARTMENT Symptoms of stridor ☐ SPECIFIC 2WW INFORMATION URGENT 2WW REFERRAL Neck lump unexplained lump in the neck ( ≥45 years) ☐ Laryngeal cancer persistent unexplained hoarseness of voice ( ≥45 years) ☐ Pharyngeal cancer Any of the following for more than 3 weeks Pain on swallowing ☐ Lateralising throat pain ☐ Throat pain that radiates to the ear ☐ Difficulty in swallowing/obstruction ☐ Sino-nasal disease > 3 week unilateral bleeding with unilateral discharge/obstruction ☐ Oral cancer > 3 week unexplained mouth ulcer ☐ Lump on lip or in oral cavity ☐ Red or white patch in oral cavity consistent with erythroplakia or erythroleukoplakia ☐ Please advise on the following (if not indicated elsewhere in your referral): Tobacco use (please specify quantity) Smoking (pipe or cigarette)- please provide pack/year history ☐ Chewing ☐ Alcohol consumption (please specify quantity) Anticoagulation and / or antiplatelet medication please state indication and medication taken: – Please provide details and the latest INR if applicable:
Suspected head and neck cancer 2 week wait referral Date of decision to refer: Date referral received at Trust: Surname: First Name: Title: Gender: DOB: / / NHS Number: Ethnicity: Language: Interpreter required: Transport required: Patient Address: Postcode: Contact numbers: Home: Mobile: Email: Usual GP Name: Practice Name : Practice Address: Practice Code: Direct line to the practice (Bypass) : Main: Fax: Email: Referring Clinician: IMMEDIATE ADMISSION TO EMERGENCY DEPARTMENT ☐ Symptoms of stridor SPECIFIC 2WW INFORMATION URGENT 2WW REFERRAL Neck lump ☐ unexplained lump in the neck ( ≥45 years) Laryngeal cancer ☐ persistent unexplained hoarseness of voice ( ≥45 years) Pharyngeal cancer Any of the following for more than 3 weeks ☐ Pain on swallowing ☐ Lateralising throat pain ☐ Throat pain that radiates to the ear ☐ Difficulty in swallowing/obstruction Sino-nasal disease ☐ > 3 week unilateral bleeding with unilateral discharge/obstruction Oral cancer ☐ > 3 week unexplained mouth ulcer ☐ Lump on lip or in oral cavity ☐ Red or white patch in oral cavity consistent with erythroplakia or erythroleukoplakia Please advise on the following (if not indicated elsewhere in your referral): Tobacco use (please specify quantity) ☐ Smoking (pipe or cigarette)- please provide pack/year history ☐ Chewing Alcohol consumption (please specify quantity) Anticoagulation and / or antiplatelet medication – please state indication and medication taken: Please provide details and the latest INR if applicable: