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\nPatient’s Postcode:  \nDentist Name:  \nPractice Name and Address:  \nGDC Number:  \nPractice Telephone Number:  \nPatients GMP Name and Address:  \nGMP Postcode:  \nGMP Telephone Number:  \n\n| The patient is aware and fully informed regarding the need for the referral: |  |  |  | The patient has been given an information leaflet and a copy of this referral form: |  |  |  | The GMP has been sent a copy of this referral form: |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| | YES | | NO | | YES | | NO | | YES | | NO |\n\n\n| Culture, Mobility, Impairment Issues: |  |  |  |\n| --- | --- | --- | --- |\n|  | Is the patient from overseas?\u003Cbr>Is the patient a temporary visitor to the county?\u003Cbr>Is disabled access required?\u003Cbr>Is transport required? | | Visual impairment?\u003Cbr>Hearing impairment?\u003Cbr>Translation or interpretation service required? If yes what language? |\n\nEthnic Origin:  \nReligion:  \n\n| Area of Suspicion: |  | Risk Factors: |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n|  | Oral cavity Pharynx Thyroid\u003Cbr>Larynx Neck / lymph node Ear\u003Cbr>Nose\u003Cbr>Other Please state... | | Poor diet Smoker Ex-smoker Alcohol – | | How many per day? For how long? |\n|  |  |  | No. units per week \u003Cbr>Paan / Betel Quid / Khat chewing Previous H&N cancer\u003Cbr>Previous cancer\u003Cbr>Previous radiotherapy Immunosuppressed HIV/AIDS\u003Cbr>Human papillomavirus |  |  |\n\nFigure 1. Please add visual extra oral sign(s) if applicable e.g. lump(s) and or swelling(s):  \nSymptoms:  \nPain on swallowing Mouth ulcer  \nUnilateral deafness Trismus  \nSore throat  \nPersistent hoarseness Nasal obstruction/discharge Lump / swelling in neck  \nBleeding  \nCranial nerve lesion Orbital mass Otalgia (ear ache) Oral swelling  \nOral white patch  \nOral red patch  \nOTHER (Detail below)  \nPlease provide other relevant information here  \nPlease describe in detail the location of lump(s) and swelling and associated history Please complete a medical history form and attach to this referral, attach additional information if required  \nI have read and understand the guide for referrals of this type.  \nSigned: Signed:  \nThis form should be faxed or e-mailed immediately to the appropriate hospital See the directory of secondary care cancer services.","cbCaipN5V3VFNyqF","https://ap.wps.com/l/cbCaipN5V3VFNyqF","pdf",392419,"English","# Patient details\n## Referral confirmation and information leaflet\n# Clinical information\n## Culture, impairment and access needs\n## Area of suspicion and risk factors\n## Symptoms and lump/swelling details\n# Declaration and submission","[{\"question\":\"What patient and contact details are required on the form?\",\"answer\":\"The form collects patient title and name, gender, date of birth, address, preferred contact number, and postcode, plus patient GMP name and address with their postcode and telephone number.\"},{\"question\":\"What does the form ask to confirm regarding the referral?\",\"answer\":\"It includes checkboxes confirming the patient is aware and fully informed about the need for the referral, and whether the patient received an information leaflet and a copy of the referral form.\"},{\"question\":\"How are suspected lesion details and risk factors recorded?\",\"answer\":\"It provides fields for area of suspicion and a list of risk factors, followed by symptom selections and a prompt to add extra oral sign(s) plus detailed location/history of any lump(s) and swelling(s).\"},{\"question\":\"Where should the completed form be sent and when?\",\"answer\":\"The template states the form should be faxed or e-mailed immediately to the appropriate hospital, referencing a directory of secondary care cancer services.\"}]","Good-Practice referral form - Medical referral template - urgent two week pathway | PDF",1789842570]