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South East London - Restorative Referral Form

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Question 1.

Preferred hospital (please note that we cannot guarantee patients will be seen at their preferred choice)

- Required.
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Type of Referral:
For Suspected Cancer please use the 2 week wait referral pathway:
KCH urgent suspected cancer referral
GSTT urgent suspected cancer referral - head and neck referral form 

- Required.
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Question 2.

If your patient does not meet the criteria for treatment in the specialist service, would you be happy for them to be seen for an assessment in the Undergraduate service?
Please note, they will only be offered treatment if they meet the criteria for Undergraduate care.

- Required.
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