Neuro Oncology MDT Referral Form

The Neuro Oncology MDT is held on Wednesday afternoons. All referrals have to be submitted prior to 12 noon on the Tuesday before, or the patient will not be discussed until the following Wednesday. Urgent opinions can be sought from the duty neuro-oncology surgeon at other times.

If there are issues with this electronic form, paper-based referrals can still be made using the referral form emailed to Sht-tr.Cancer-NeuroOncology@nhs.net. The MDT coordinator can be contacted on 0114 2268721.

– Referrer Information

Referring Consultant

Consultant's Email Address

Speciality

Hospital

Referrer's Name

Referrer's Grade

Referrer's Email Address

Referrer's Contact Phone Number for Referral Queries

Email Address for MDT Outcome

+ Patient Details

Patient Name

Patient Date of Birth

NHS Number

Gender

Current Inpatient

Inpatient Location

Patient's Home Address

+ Pathology

Question To MDT

Current Clinical Condition (conscious level/neurology/cormorbidities)

Details of Previous Cancer Treatment (including current staging or primary disease and prognosis)

Additional relevant information (eg emotional, social, spiritual needs), including requirements for dietetics/physio/OT/SALT

WHO Performance Status (grade most appropriate)

Prognosis (select most appropriate)

Has the patient been told they might have a brain tumour?

Is the patient aware of this referral and can be contacted directly by us?

+ Medication

Current/Recent Anticoagulants (include date stopped if recently held)

Current/Recent Antiplatelets (include date stopped if recently held)

Dexamethasone, including current dose and frequency

+ Imaging

In the majority of cases a contrast MRI is required. It is essential all imaging is transferred to the STH PACS before the MDT deadline.

Imaging Hospital

MRI Brain Performed

MRI Date

Please Confirm the MRI Has Been Transferred to STH

CT Head Performed

CT Date

Please Confirm the CT Has Been Sent to STH PACS

+ Other

Attachments

Upload additional documents (PDF or Word, up to 5 files)

Drag & drop files here or click to select

You can upload up to 5 files. Max size: 10MB per file.