Urological Cancers SMDT Meeting Referral Form

NEURO-ONCOLOGY MDT Meeting Referral Form

BEFORE CONTINUING WITH THIS REFERRAL YOU MUST DISCUSS YOUR PATIENT WITH THE NEUROSURGICAL SpR ON CALL (via QMC Switchboard 0115 924 9924) OTHERWISE THIS REFERRAL WILL NOT BE ACCEPTED. SpR on call

Date discussed w/ SpR

Patient Details Referring Doctors Details Name Referring Hospital D/O/B Referring Clinician Current Consultant Location in Charge NHS No. Contact details to return MDT outcome to (will be sent following the MDT on a Friday afternoon) Address Telephone number:

Email address:

Current S ymptoms:

Performance S tatus: Steroids?(please include dosage):

Reason for MDT Discussion: Discussed at MDT Previously?

Previous Medical History (including, if applicable, details of previous oncology treatments):

Investigations: CT CAP / MRI (contrast) / CT (contrast) / CT (no contrast) / MRI (no contrast)

At which Trust / Private Hospital was the imaging taken? (if outside of NUH please make arrangements for this to be exported to IEP):

Referrals can be emailed to: If referring from another nuh.nhs.uk email address - [email protected] If emailing from outside of NUH – [email protected]