This form should be submitted via the Referral Support Service
Reference/Priority
Referral Date:
Referral Date	

	Priority:
2WW	

	NHS Number:
NHS Number	

Patient Details
Title:
Title	

	Forename(s):
Given Name	

	Surname:
Surname	

Date of Birth:
Date of Birth	

	Gender:
Gender	

	Ethnicity:
Ethnic Origin	

Contact Details
Address Line 1:
Home Address House Name/Flat Number	

	Address Line 2
Home Address Number and Street	

	Address Line 3:
Home Address Village	

Town:
Home Address Town	

	County:
Home Address County	

	Postcode:
Home Address Postcode	

Phone:
Patient Home Telephone	

	Mobile:
Patient Mobile Telephone	

	Text Message Consent:

	
Email:
Patient E-mail Address 	

Referrer/Practice Details
Referring Name:
Referring User	

	Referrer Code:
Free Text Prompt 	

	Practice Code:
Organisation National Practice Code	

Clinic Details
Specialty:
2WW	

	Clinic Type:
2WW Skin	

	Named Clinician:
     	

Patient Choice Preferences
Provider 1:
Referral Target Service Name 	

	Provider 2:
     	

Preferences
Vulnerable Patient:

	Vulnerable Reason:
     	

	Confidential/Silent Referral:

	
Preferred Contact Time:
     	

	Interpreter Required:

	Preferred Language:
Main Language 	

Referral Details
Non-clinical information for the booking team:
     	

Provisional Diagnosis:
     	

Smoking Status:
Single Code Entry: Smoking Status  	

Referral Reason/Letter Text

If your patient does not meet any of the NICE defined 2WW criteria please liaise (by phone or Advice and Guidance) with a specialist or send them in as an urgent referral. Please do not annotate 2WW forms with your own criteria.
Referral Information
Please see the Suspected Skin Cancer Guidance for an explanation of which lesions should be referred via this service. This referral form should not be used for BCCs or for lesions on the following special sites: on the vermillion, anus, penis and vulva.	
Patient Awareness
Confirm that your patient understands that they have been referred onto a “suspected cancer pathway”:		

Confirm that your patient has received the information leaflet		

Confirm that your patient is available to attend an appointment within 2 weeks of this referral**		

** If, after discussion, your patient chooses to not attend within 2 weeks, when will they be available:
     	

Main lesion (tick appropriate boxes)
If more than 1 lesion, describe other lesions in the text box at the end of this section
Suspected diagnosis – Please tick		

	Pigmented lesion with a weighted 7-point checklist of 3 or more	

	Pigmented / non-pigmented lesion that suggests nodular melanoma	

	Nail changes e.g. pigmented line or new pigmentation under nail	

	Biopsy confirmed diagnosis of melanoma (send histology report)	
				
NICE guidance		

	Suspected SCC	

	Another form of skin cancer (but not a BCC)	
NICE guidance		

	Weighted 7 Point Check List for assessment of pigmented lesions
Suspicion is greater if 3 or more but strong concerns about any feature should prompt referral	
				
		Major features of the lesion (2 points each):	

	Change in size	

	Irregular shape or border	

	Irregular colour	
			
		Minor features of the lesion (1 point each):	

	Largest diameter 7mm or more	

	Inflammation	

	Oozing or crusting of the lesion	

	Change in sensation (including itch)	
Photo of Lesion (tick appropriate box)
For more information on medical photography please read the Medical Photography Leaflet
Photo Attached?	CCG policy on photography for dermatology referrals (link to commissioning statement when published)	
Overview	Yes		

	No		

Close up image	Yes		

	No		

Dermatoscopic image	Yes		

	No		

For guidance on how to take a suitable photograph and the benefits of teledermatology please see the RSS website	A photo has not been included because (select from the drop-down list)

*If dermatoscopic equipment broken or unavailable for other reason please still include a normal overview and close up image

** Where patients decline photography referrers should confirm here 

 I confirm my patient declines photography even though I have explained the benefits to them (and other patients), that photographic review of lesions enables.

Please complete page 5 onwards if photos are not attached	
History of lesion – Duration (tick appropriate box)
<1 month:		

	1-3 months:		

3-6 months:		

	6-12 months:		

>12 months:		

History of lesion – Growth (tick appropriate boxes)
Regressed		

	Static		

	Slow		

	Fast		

Additional information
Immunosuppression:
Details:      	

	Previous Skin Cancer:
Details:      	

	
Family History of Skin Cancer:
Details:      	

	More than 100 normal moles
(not a reason for 2WW referral alone)		

Atypical moles (particularly if multiple) (not a reason for 2WW referral alone)		

	History of high UV exposure e.g. tanning beds, living abroad		

Other relevant information, please note below:
     	

Have you performed a full skin survey (tick appropriate box)
Yes:		

	No:		

More than one lesion?
If the patient has more than 1 lesion, please state the size, appearance, duration and growth of each subsequent lesion:
     	

Omit next sections if photos are attached
See next sections if photos are not attached to referral
Size of main lesion (tick appropriate box)
0-6mm:		

	7-15mm:		

16-20mm:		

	>20mm:		

Appearance (tick appropriate boxes)
Irregular shape:		

	Irregular colour:		

Crusting/oozing:		

	Inflammation:		

Scaling:		

	Itch/change in sensation:		

Bleeding:		

	Induration:		

Site of main lesion (tick appropriate boxes)
Please supply any additional information in the free text box provided
Abdomen:
     	

	Arm:
     	

	
Back:
     	

	Buttock:
     	

	
Chest:
     	

	Cheek:
     	

	
Chin:
     	

	Ear:
     	

	
Eye:
     	

	Feet:
     	

	
Forehead:
     	

	Hand:
     	

	
Leg:
     	

	Mouth:
     	

	
Neck:
     	

	Nose:
     	

	
Scalp:
     	

			

Patient Readcoded Values
EHIC: Single Code Entry: European health insurance card (EHIC) held  
Smoking Status: Single Code Entry: Smoking Status  
Religion: Single Code Entry: Religion  
Active Problems
Family History
Problems
Values and Investigations 
Allergies
Alcohol Consumption
Smoking
Weight
Height 
Blood Pressure
BMI
Medication
Medication
Lab Results
Radiology
HbA1c
Urinalysis
Haematology
Lipids
Diagnostics
ECG
Peak Flow
Cervical Smear