Referral Form

These forms are only for tertiary referrals from other hospitals. We will not accept referrals from GPs using the online referral form below.

If you are a GP referring to the RNOH please use the NHS e-referral system, e-RS.

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Demographics

Patient details

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Referring Team

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Diagnosis

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*Myeloma Subtype is required

*Light Chain Type is required

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Imaging Completed:

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*Date of CT is required

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*Date of Skeletal Survey is required

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Radiological and Clinical:

 

Radiological evidence of neural compression:

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Symptoms of altered neurology:

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Chemotherapy / Radiotherapy / Cancer Treatment:

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*Date Chemotherapy commenced is required

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Tumor Markers

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*FISH Type is required

Renal function

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Other Comments

Please use this space for any other comments or to tell us about any other medical co-morbidities the patient may have and not covered above

Thank you for your referral. Our myeloma coordinator will confirm all imaging has been received and will contact the referrer / designated contact to arrange clinic appointments.

If your patient develops abnormal neurology, the case must be discussed with the on-call spinal surgical team at the Royal National Orthopaedic Hospital.

Please click the button below to submit your form. You will receive an automated email confirming successful submission to the Referrer’s Email address.