2 week Urgent Referral for Suspected Head & Neck Cancer (excluding Thyroid) February 2018 background and culture Patient’s details Patient’s Surname Ethnicity Forename 1st language Known As Interpreter required? Y N DOB Age GP details Sex Title NHS No Referring GP Address & GP address Postcode GP Tel no Hospital GP Fax no No Practice Email Email Can leave Preferred Referral Dates Phone Numbers Number(s) Home Referral date Work Date received Dentist details (if known) Name Telephone Number Practice Fax Number 2ww referral communication checklist it is essential that you answer all questions in this section I have explained to the patient that they may have cancer and I am Yes No why not? – referring them on the 2 Week Wait Suspected Cancer Pathway Is the patient available for an appointment within the next 14 NB. Please only submit this referral Yes days? when the answer is Yes Has the patient been given the Fast Track Pathway information leaflet? Yes No why not? – Information leaflets can be printed from here occg.info/2WW-PIL Ctrl-Click IMPORTANT: Please ensure this patient is available from referral for further hospital appointments and investigations. Failure to check this may result in wasted appointments. If the patient cannot attend immediately (e.g. booked travel) please negotiate a delay in referral. Please indicate any exceptional circumstances here I have explained to the patient that, to ensure they are seen Yes No why not? – within
2 week Urgent Referral for Suspected Head & Neck Cancer (excluding Thyroid) February 2018 Patient’s details Patient’s background and culture Surname Ethnicity Forename 1st language Known As Interpreter required? Y N DOB Age Sex Title GP details NHS No Referring GP Address & Postcode GP address GP Tel no Hospital No GP Fax no Email Practice Email Phone Numbers Preferred Number(s) Can leave Referral Dates Home Referral date Work Date received Dentist details (if known) Name Telephone Number Practice Fax Number 2ww referral communication checklist it is essential that you answer all questions in this section I have explained to the patient that they may have cancer and I am referring them on the 2 Week Wait Suspected Cancer Pathway Yes No – why not? Is the patient available for an appointment within the next 14 days? Yes NB. Please only submit this referral when the answer is Yes Has the patient been given the Fast Track Pathway information leaflet? Information leaflets can be printed from here Ctrl-Click occg.info/2WW-PIL Yes No – why not? IMPORTANT: Please ensure this patient is available from referral for further hospital appointments and investigations. Failure to check this may result in wasted appointments. If the patient cannot attend immediately (e.g. booked travel) please negotiate a delay in referral. Please indicate any exceptional circumstances here I have explained to the patient that, to ensure they are seen within Yes No – why not?
2WW-Suspected-Head-and-Neck-Cancer-Blank-v91.docx