Stereotactic Radiosurgery MDT Referral Form
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Stereotactic Radiosurgery MDT Referral Form
This referral form is currently under development. DO NOT USE for live referrals yet.
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Referrer Information
Consultant
Speciality
Hospital
Email Address
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Patient Details
Patient Name
Patient Date of Birth
NHS Number
Gender
Please select...
Male
Female
Patient aware of current diagnosis
Please select...
Yes
No
Patient aware of referral for potential management
Please select...
Yes
No
Patient can be contacted directly regarding further management
Please select...
Yes
No
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Pathology
Diagnosis
Please select...
AVM
Meningioma
Vestibular Schwannoma
Cavernoma
Trigeminal Neuralgia
Haemangioblastoma
Pituitary Tumour
Other
Details of 'Other' pathology
Side
Please select...
Left
Right
Both
Spetzler Martin Grade
WHO Grade
Please select...
Not known (no histology)
Grade 1
Grade 2
Grade 3
Question To MDT
Presentation
Past Medical History
None
Previoius Cranial Surgery (including burr holes, craniotomies, shunts etc.)
Other Relevant Treatment
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Imaging
Imaging Hospital
MRI Performed
Please select...
Yes
No
Not Indicated
Contraindicated
Latest MRI Date
CT Performed
Please select...
Yes
No
Not Indicated
Latest CT Date
Angiogram Performed
Please select...
Yes
No
Not Indicated
Contraindicated
Latest Angiogram Date
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Attachments
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Drag & drop files here or click to select
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