colorectal referral form - Nwlcn.nhs.uk

NORTH WEST LONDON CANCER NETWORK
URGENT SUSPECTED COLORECTAL CANCER REFERRAL FORM
To make a referral, FAX this form to the Urgent Referral Team at the relevant hospital (see overleaf). If you
wish to send an accompanying letter, please do so. All referrals must be FAXED.
Hospital to which patient is being referred :
Patient details
NHS No:
Surname:
First Name:
GP Details
Dr:
Address:
Age/D.O.B Sex: M / F Tel: Fax
Address:
E-mail:
Postcode
Date of decision to refer:
Tel day: Tel eve: Signature:
Have you informed the patient that you suspect colorectal cancer Y / N
Have you told the patient they will be seen within 2 weeks
Y / N
Has the patient had a previous diagnosis of cancer Y / N (Specify if known)
Has the patient previously visited this hospital Y / N
Hospital number (if known):
First language:
Interpreter required Y / N
Abdominal Examination performed Y / N P.R Examination performed Y / N
Symptoms and Clinical Findings
1. A definite abdominal or palpable rectal (not pelvic) mass on PR examination all ages
2. Rectal bleeding WITH a change in bowel habit to looser stools and/or
increased frequency of defecation persistent for 6 weeks
3. Iron deficiency anaemia WITHOUT an obvious cause
(Hb< 11 g/dl in men or 60yrs
∗ Anal symptoms include soreness, discomfort, itching, lumps and prolapse as well as pain
5. Change in bowel habit to looser stools and/or increased frequency
of defaecation, WITHOUT rectal bleeding persistent for six weeks.
> 60yrs
Patient previously investigated for abdominal or Bowel problems Y / N
If Yes :
Consultant name
Date:
Findings:
Other information relevant to this referral (e.g. past history, family history, specific anxiety, relevant
medications, etc.):
Please ensure this form is received in the Trust within 24 hours of GP decision to refer

North West London
Hospitals NHS Trust
Fax: 020 8235 4188
Tel: 020 8235 4293
Ealing Hospital NHS
Trust
Fax: 020 8967 5005
Tel: 020 8967 5000, x3921
Imperial College Healthcare
NHS Trust
Hammersmith Hospital
Fax: 020 3313 8383
Tel: 020 3313 4877
Charing Cross Hospital
Fax: 020 3311 7564
Tel: 020 3313 5000
St Mary’s Hospital
Fax: 020 3312 1580
Tel: 020 3312 1527
Hillingdon Hospital NHS Trust
Fax: 01895 279284
Tel: 01895 279891
2WW dedicated fax line : 01895
279807
Chelsea and Westminster
NHS Foundation Trust
Fax: 020 8746 8814
Tel: 020 8237 2679
West Middlesex
University Hospital NHS
Trust
Fax: 020 8321 5157
Tel: 020 8321 6776
Please ensure this form is received in the Trust within 24 hours of GP decision to refer