Nottingham NHS Treatment Centre

Dermatology BCC

Z018: Patient referral

Known Bowen’s disease (IEC) or Actinic keratoses should be managed in primary care, see guidelines:

http://www.bad.org.uk/shared/get-file.ashx?id=40&itemtype=document (Actinic Keratosis) http://www.bad.org.uk/shared/get-file.ashx?id=1986&itemtype=document (Bowens Disease)

If no appointment is available using the e referrals please select defer to provider.

Section 1 Patient information (Please complete in BLOCK CAPITALS)
Surname: First name: Mr Miss Mrs Ms Other: Date of birth:	Date of referral: NHS number: UBRN: Home telephone number:
Address: Postcode:	Mobile / daytime telephone number: Transport: Yes No Mobility: Interpreter: Yes No Ethnicity: Language:
Section 2 Practice information (Please use practice stamp if available)
Referring GP:	Locum: Yes No
Practice address: Postcode:	Telephone: Fax:
Section 3 Clinical information (please all applicable entries) Please enclose print outs of CURRENT medications and PAST MEDICAL HISTORY
Characteristics: Ulcerated crusted or scabbed lesion not healing Pearly border Histological diagnosis of BCC	Location: Head or neck Body Please specify:	Risk factors: Previous BCC Prolonged UV exposure Immunosuppresion

Section 4 Past medical history
Section 5 Medication
Section 6 Additional clinical details
Section 7 Performance status
ECOG PERFORMANCE STATUS (please tick one of the following statements about the patient) 0 – Fully active, able to carry on all pre-disease and performance without restriction 1 – Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature e.g light house work, office work 2 – Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours 3 – Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours 4 – Completely disabled. Cannot carry out any selfcare. Totally confined to bed or chair.

Discussed urgent suspected cancer referral with patient: Yes No
Is the patient aware they have been referred on the “2 Week Wait” pathway?: Yes No
Does the patient have any holiday plans within the next 2 months: Yes No If yes, please give details:

Any Communication Needs
Hospital use only:
Date referral received:
Patient contacted:

It is important the relevant information sheet is given to the patient when they are referred under the 2ww priority.

The latest patient information sheets were updated in April 2015 in line with NICE guidance. To download the patient information sheets, please click on the link: http://www.nottinghamchooseandbook.nhs.uk/index.php/county-two-week-wait/17-county-2ww-patient-information-sheets

Nottingham University Hospitals	CircleNottingham

Two Week Wait Office	Nottingham NHS Treatment Centre

Nottingham Cancer Centre	Queen’s Medical Centre Campus

City Hospital Campus	Lister Road

Hucknall Road	Nottingham NG7 2FT

Nottingham NG5 1PB	T: 0115 970 5800 extension 10011

T: 0115 840 5801	F: 0115 978 8765

F: 0115 840 5802	Contact: Zoe.Brindley@circlenottingham.co.uk

E: TwoWeekWaitOffice@nuh.nhs.uk	circlenottingham.co.uk

CircleNottingham is run on behalf of the NHS. CircleNottingham is a subsidiary of Circle Health Limited. Circle is the registered trademark and trading name of Circle Health Limited.