SOUTH WEST LONDON CANCER NETWORK: Lung Cancer Referral Form

SOUTH WEST LONDON CANCER NETWORK Suspected Lung Cancer Referral Form (NICE 2006)

Date of GP decision to refer: No of pages faxed: Urgent Referrals Criteria (Please tick category) GP DETAILS Urgent referral for a chest x-ray: GP Name & Initials: GP Practice Code:  Haemoptysis  Address: Post Code:  Unexplained changes in existing symptoms in patients with chronic respiratory problems, or  new persistent problems (more than 3 weeks):

Cough, chest or shoulder pain, dyspnoea, weight loss, Telephone No: Fax No: chest signs, hoarseness, finger clubbing, features suggesting a metastasis from the lung, persistent cervical or supraclavicular lymphadenopathy, fatigue

Urgent suspected cancer 2 week wait faxed referral to PATIENT DETAILS Chest Physician - any of the following: Last Name: First Name: LG1 Chest x-ray suggestive or suspicious of lung cancer  Address: Post Code: LG2 Persistent haemoptysis in smokers/ex-smokers over 40 years of age  LG3 Signs of superior vena caval obstruction  LG4 Stridor (consider emergency referral for admission)  Daytime Tel or Mobile: Gender: M  F  X-ray result: - must be attached Date of Birth: Abnormal  Age: Attached  Interpreter required? Y / N Language: Ethnicity: NB: If the chest x-ray is normal and the GP is still Hospital No: concerned or suspicious then an urgent referral NHS No: should be made. COMMENTS/OTHER REASONS FOR URGENT REFERRAL

Patient Awareness Questions:

1. Has the patient been made aware of the nature of their referral? Yes  No  2. Has the patient been supplied with supportive information about the Urgent Suspected Cancer referral process? Yes  No  3. Have you asked the patient if they will be available to attend an appointment within the next two weeks? Yes  No  4. Has the patient indicated to you that they would be available to attend an appointment within the next two weeks? Yes  No 

SOUTH WEST LONDON CANCER NETWORK How to make urgent referrals for suspected lung cancers

Please FAX / EMAIL this form to the Cancer Office at the relevant hospital, with or without an accompanying letter. E-Mails MUST be sent from a NHS.net address. Please ensure that the referral reaches the hospital within 24 hours of the GP’s decision to refer.

Epsom and St Helier NHS Trust Epsom and St Helier NHS Trust

Epsom General Hospital St Helier Hospital Dorking Road, Epsom Wrythe Lane, Carshalton Surrey KT18 7EG Surrey SM5 1AA

FAX: 020 8296 2741 FAX: 020 8296 2741

TEL: 020 8296 2742 TEL: 020 8296 2742

Croydon Health Services NHS Trust St George’s Healthcare NHS Trust

Croydon University Hospital St George’s Hospital London Road, Croydon Blackshaw Road, Tooting Surrey CR7 7YE London SW17 0QT

FAX: 020 8401 3337 FAX: 020 8725 0778

TEL: 020 8401 3986 TEL: 020 8725 1111

E-MAIL : [email protected]

Kingston Hospital NHS Trust Kingston Hospital NHS Trust

Kingston Hospital Queen Mary’s Hospital Galsworthy Road Roehampton Lane Kingston KT2 7QB London SW15 5PN

FAX: 020 8934 3306 FAX: 020 8812 7937

TEL: 020 8934 3305 TEL: 020 8487 6037 / 6032