Demographics

Patient details

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Referring Team

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Diagnosis, if applicable:

*Myeloma Subtype is required

*Light Chain Type is required

Tumor Markers if applicable:

*FISH Type is required

Radiological and Clinical

Radiological evidence of neural compression

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Symptoms of altered neurology

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Imaging Completed

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*Date of MRI is required

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*Date of CT is required

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*Date of Skeletal Survey is required

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Previous Cancer Treatment / Chemotherapy / Radiotherapy:

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*Date Chemotherapy commenced is required

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Medical History

Respiratory

Other

Drug History

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Reason for Referral / Questions for MDT

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. One of our team will contact the referrer with feedback from the team as soon as possible and within normal working hours.

If your patient develops abnormal neurology, the case must be discussed with the on-call spinal surgical team at the Royal National Orthopaedic Hospital (via the switchboard: Contact us).

You will receive an automated email confirming successful submission to the Referrer’s Email address.