<p> SOUTH WEST LONDON CANCER NETWORK Suspected Lung Cancer Referral Form (NICE 2006)</p><p>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):</p><p>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</p><p>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</p><p>Patient Awareness Questions:</p><p>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  </p><p>SOUTH WEST LONDON CANCER NETWORK How to make urgent referrals for suspected lung cancers</p><p>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.</p><p>Epsom and St Helier NHS Trust Epsom and St Helier NHS Trust</p><p>Epsom General Hospital St Helier Hospital Dorking Road, Epsom Wrythe Lane, Carshalton Surrey KT18 7EG Surrey SM5 1AA</p><p>FAX: 020 8296 2741 FAX: 020 8296 2741</p><p>TEL: 020 8296 2742 TEL: 020 8296 2742</p><p>Croydon Health Services NHS Trust St George’s Healthcare NHS Trust</p><p>Croydon University Hospital St George’s Hospital London Road, Croydon Blackshaw Road, Tooting Surrey CR7 7YE London SW17 0QT</p><p>FAX: 020 8401 3337 FAX: 020 8725 0778</p><p>TEL: 020 8401 3986 TEL: 020 8725 1111</p><p>E-MAIL : [email protected]</p><p>Kingston Hospital NHS Trust Kingston Hospital NHS Trust</p><p>Kingston Hospital Queen Mary’s Hospital Galsworthy Road Roehampton Lane Kingston KT2 7QB London SW15 5PN</p><p>FAX: 020 8934 3306 FAX: 020 8812 7937</p><p>TEL: 020 8934 3305 TEL: 020 8487 6037 / 6032</p>