(cache)WH Open Access Referral to Excision of Skin Lump

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WH Open Access Referral to Excision of Skin Lump

10 mins estimated time to complete

Please read the following before continuing: 1.Only ambulant healthy individuals who are agreeable for LA (i.e. no phobia of blood or needles) should be referred for Direct Access Surgery. 2. Patients with these conditions are not suitable for Direct Access Surgery: • Below 16 years old • Non-ambulant patients with poorly controlled comorbidities • On antiplatelets/ anticoagulants • Require GA/ Monitored Anesthesia Care (MAC) • Allergy to LA • Uncooperative patients • Uncertainty about origin or nature of lump (e.g. parotid/ submandibular gland origin) 3. Refer to the table below for the inclusion and exclusion criteria for each surgical discipline.

Please ensure above referral criteria is met.

Type of Referral

1.Type of Referral

GP Private (non-subsidised)GP CHAS/PG/MG (subsidised)

Patient Particulars

2.Patient's Name (as per NRIC/FIN/ID)

3.NRIC/FIN/ID Number

4.Date of Birth

No date selected

5.Patient's/Next-of-Kin's Contact Number (Mobile)

6.Patient's/Next-of-Kin's Contact Number (Home)(optional)

7.Patient's/Next-of-Kin's E-mail

Referring Centre Particulars

8.Clinic Name (Clinic Branch, if any)

9.Email

You will receive a copy of the submitted referral form via this e-mail

A copy of the responses will be sent to this email address

10.Clinic Contact Number

11.Referring Doctor's Name

12.MCR Number

Please input with "M" e.g. M01234A

13.Referring Doctor's Contact Number (Mobile)

We will contact you at this number for clarifications with regards to the referral form details.

Requested Procedure

14.Please select the requested procedure:

(GS) Excision of Skin Lump(Ortho) Excision of Skin Lump(ENT) Excision of Skin Lump

15.I have taken verbal consent from patient/ NOK (if patient unable to give consent)

Yes

16.I have briefed patient on the requested procedure. Copy of the Patient Information Sheet has been given.

Yes

17.Do you require further discussion with a specialist on the case?(optional)

Our specialist will give you a call once the referral form has been received and reviewed.

Yes

Relevant History

18.Past Medical History

Any cancer history, any constitutional symptoms (e.g. loss of weight/ appetite) and other relevant details for procedurist to note

19.Anti-coagulants

WarfarinDabigatranRivaroxabanApixabanEdoxabanNIL

Others

20.Bleeding Disorders

Yes

21.Drug Allergy

Yes

22.Regular Medications

Yes

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