Teledermatology Referral Form

Please submit this referral form via e-RS
Patient	Referrer	
Name	Title Given Name Surname 	Name	Current User 	
Address	Home Full Address (single line) 	Practice Name	Usual GP Organisation Name 	
Telephone	Patient Home Telephone      	Practice Address	Usual GP Full Address (single line) 	
Mobile	Patient Mobile Telephone       	GP Practice code	Usual GP Organisation National Practice Code 	
Date of Birth	Date of Birth 	Telephone	Usual GP Phone Number      	
NHS Number	NHS Number 	Fax	Usual GP Fax Number      	
Gender	Gender(full) 	Email (NHS)	Organisation E-mail Address      	
Email	Patient E-mail Address      			
Ethnicity	Ethnic Origin 	Date of this referral	Short date letter merged 	
Enfield Registered Patient?	Yes  No 	
Where a F2F or in-person appointment is felt necessary, following virtual triage, which hospital would the patient prefer to be seen at?	NMUH 
RF Barnet and Chase Farm 	
*Where the patient would prefer to be seen at NMUH please inform the GP so that they can arrange for a F2F appointment at the Trust. Please DO NOT book them in for a F2F or in-person appointment at the Royal Free	

Interpreter required? 	Yes      No 	
Main spoken language or state if deaf requiring interpreter 	Main Language      

Deaf requiring interpreter?   Yes   No 
	
Any other information (e.g. accessibility requirements, carer information, etc.) 	Transport required?   Yes     No 

Carer related codes recorded: Is a carer 
Learning Disabilities related codes recorded: Learning disabilities administration status
      

Teledermatology Exclusion Criteria 
Lesions	Rashes	
Refer 2ww all patients with suspected melanoma, squamous cell carcinoma or any other suspicious rapidly enlarging lesion within 4-8 weeks (includes rapidly increasing basal cell carcinomas).	All patients with acute onset and/or rapidly spreading severe rashes involving >50 % of body surface area should be referred urgently to the on call SpR	
Refer Routinely and not via Teledermatology	
Paediatric patients (15 years old and under) 	
Patients with anogenital skin lesions	
Patients without capacity to make informed decisions/consent to photography/understand the English language	
Patients previously diagnosed with melanoma and/or non-melanoma skin cancer (including BCC) and that would benefit for a total body face-to-face examination	Patients with a  severe skin disease or chronic dermatological condition previously seen in 20 care and known to require 20 care input	
Patients with >3 lesions for review (as these warrant a full body check). This also includes  patients for mole mapping	Patients whose condition is not amenable to photographic imaging e.g. Hyperhidrosis	
Patients with immunosuppression. 		

Patient consented to images being taken and attached to referral?* (please insert images at the bottom of this referral form)     Yes        *Mandatory    

Patient consented to photographs being used for teaching purposes providing these are anonymised?     Yes    No 

Family history of melanoma?                No     Yes       

History of excessive sun exposure?     No      Yes       

Description of current problem(s), clinical findings (including site, size), diagnosis (if known), treatments so far and impact on patient (sleep, work, etc.):

     

Other Medical Problems (including any psychiatric conditions, psychological or difficulties that may affect treatment compliance): 

Problems
     

Current Medication:

Medication 
     

Allergies:

Allergies
     

Tobacco Consumption: Single Code Entry: Tobacco smoking consumption        	Alcohol Consumption: Single Code Entry: Alcohol consumption        	
Height: Single Code Entry: O/E - height        	Weight:  Single Code Entry: O/E - weight       	
BMI: Single Code Entry: Body mass index        	Blood Pressure: Single Code Entry: O/E - blood pressure reading       	

	Please insert images below: