Suspected Skin Cancer Referral Form

Patient Details
Surname: <Patient Name>	Date of Birth: <Date of Birth>
Forename(s): <Patient Name>	Gender: <Gender>
Address (inc postcode): <Patient Address>	NHS Number: <NHS number>
Telephone Numbers Please check tel nos with patient	Tel No (Home): <Patient Contact Details>	Tel No (work): <Patient Contact Details>	Tel No (Mobile): <Patient Contact Details>
GP Details
Referring GP: <Your Name>	GP Tel No: <Organisation Details>
Practice Name: <Organisation Address>	Practice Email Address: <Organisation Details>
Practice Address: <Organisation Address>	Date of decision to refer: <Today's date>

Patient Information
Does your patient have a learning disability?	Yes No
Is your patient able to give informed consent?	Yes No
Is your patient fit for day case investigation?	Yes No
If a translator is required, please specify language:
Is patient on any of the following medications?
Aspirin	Yes No	Indication for therapy:
Clopidogrel /Prasugrel etc .	Yes No	Indication for therapy:
Warfarin	Yes No	Indication for therapy:
NOAC (Rivaroxaban etc.)	Yes No	Indication for therapy:
Insulin	Yes No

It would be helpful if you could provide performance status information (please select as appropriate) Fully active Able to carry out light work Up & about 50% of waking time Limited to self-care, confined to bed/chair 50% No self-care, confined to bed/chair 100%

Please confirm that the patient is aware that this is a suspected cancer referral	Yes	No
Please indicate your level of cancer concern:	Low	Medium	High
Date(s) that patient is unable to attend within the next two weeks: If patient is not available for the next 2 weeks, and aware of nature of referral, consider seeing patient again to reassess symptoms and refer when able and willing to accept an appointment.
REASONS FOR REFERRAL
All patients should meet NICE guidelines for suspected cancer 2015 Please detail your reasons for referring, presenting symptoms and your examination findings
IN ALL CASES PLEASE GIVE THE NUMBER OF LESIONS OF CONCERN
1 Lesion	2 Lesions	>2 Lesions

Malignant Melanoma
Dermoscopy suggests melanoma of the skin
Pigmented or nonpigmented skin lesion that suggests nodular melanoma e.g. bleeding or vascular nodule unless definite benign diagnosis
Suspicious pigmented skin lesion with a weighted 7 point checklist score of 3 or more:
Major features (scoring 2 points each):	Minor features (scoring 1 point each):
Change in size	Largest diameter 7 mm or more
Irregular shape	Inflammation
Irregular colour	Oozing
Change in sensation

Squamous cell carcinoma
Skin lesion that raises the suspicion of squamous cell carcinoma or where SCC is in your differential diagnosis (eg keratoacanthoma or atypical wart)
Location	Upper Arm	scalp / face
Forearm	Trunk
Dorsum of hand	Lower Leg
Finger
Size	Smaller than 1.5cm diameter	Larger than 1.5cm diameter
What is the largest dimension? :

Basal cell carcinoma Only high-risk BCC requires assessment via a suspected cancer pathway. It is essential that the referrer provides the following information to facilitate triage. Lesions that are lower risk may be seen via a different urgent pathway, and the referrer delegates responsibility to the specialist team to make this decision.
Lesion Size:	0-10mm	10-20mm	>20mm
Border	Well defined	Poorly Defined
Location: ‘	Mask areas on face (central face, periorbital, eyebrows, nose, lips, chin, mandible, preauricular, postauricular, temple, ears)	Other areas on face
Hands, Nail folds, Genitals, pretibial, ankles, feet	Trunk and other locations on extremities
Immunosuppressed	Yes	No
At site of previous radiotherapy	Yes	No
This is a recurrence	Yes	No

Clinical Summary
Clinical History (significant past and current medical history): <Summary(table)>
Current Medication: <Medication(table)>
Blood Tests (if available – last 3 months): <Pathology & Radiology Reports(table)>
Allergies: <Allergies & Sensitivities(table)>
Smoking: <Diagnoses(table)>
BMI (if available): <Latest BMI>
Alcohol (if available):
Most recent blood pressure: <Latest BP>
Most recent HbA1c:

For hospital to complete UBRN: Received Date: