Referral Summary GP Care Community Urology Service *Referring GP *Practice No. *Date of Referral: *Patient’s First Name: Family Name: *Patient’s *Address: *Date of birth: *Gender: *Postcode: * Male Female   *Tel No: *NHS number: *Mobile Number: Special/Social needs: * Mandatory Fields Hearing Visual Cognitive      None Mobility impairment impairment impairment impairment Signs/Symptoms:      Visible haematuria Non-visible haematuria Raised PSA LUTS Recurrent UTIs    Continence Scrotal Lumps Testicular Pain Other Assessment Direct Access USS   Urodynamics Kidney USS Bladder USS Testes Clinical History and Examination Detail: Is Fast Track required? Is patient aware of suspected diagnosis? (Cancer 2WW) Yes No Yes No Medication: None Steroids Warfarin Asprin Heart Valve replacement Test Results: (Enter date and result) Dipstick Result MSU PSA eGFR Blood ACR DRE Result Pressure 2 out of 3 + ve Result ml/min Result Performed Please circle with dates µg/l Haematuria Raised PSA Yes No  Lower Urinary Tract Symptoms Yes No Recurrent UTIs Yes No Other Yes No Signed: Date: dd/mm/yyyy ………………………………………
Referral Summary GP Care Community Urology Service *Referring GP *Practice No. *Patient’s First Name: *Date of Referral: *Patient’s Family Name: *Address: *Date of birth: *Gender: *  Male  Female *Postcode: *NHS number: *Tel No: *Mobile Number: Special/Social needs: * Mandatory Fields  None  Hearing impairment  Visual impairment  Cognitive impairment  Mobility impairment Signs/Symptoms:  Visible haematuria  Non-visible haematuria  Raised PSA  LUTS  Recurrent UTIs  Scrotal Lumps  Testicular Pain  Other Continence Assessment Direct Access USS Kidney  USS Bladder  USS Testes Urodynamics Clinical History and Examination Detail: Is Fast Track required? (Cancer 2WW) Yes No Is patient aware of suspected diagnosis? Yes No Medication: None Steroids Warfarin Asprin Heart Valve replacement Test Results: (Enter date and result) Dipstick Result 2 out of 3 + ve with dates MSU Result PSA Result µg/l eGFR ml/min Blood Pressure ACR Result DRE Performed Please circle Haematuria Raised PSA Yes No  Lower Urinary Tract Symptoms Yes No Recurrent UTIs Yes No Other Yes No Signed: ……………………………………… Date: dd/mm/yyyy
gp-care-urology-referral-form.docx