Leeds ccgs Targeted Interventions Referral Form Hospital Referral for Anal Skin Tag Surgery



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Leeds CCGs Targeted Interventions Referral Form
Hospital Referral for Anal Skin Tag Surgery


Referral to:

(insert patient’s choice of hospital)

Patient Details:

Title


Surname

Forename(s)

Address

D.O.B


NHS Number

Tel (home)

Tel (mobile)

Gender Ethnicity Age

Is an interpreter required Yes No

Is transport required Yes No



Referrer Details:

Referring GP

Practice Address

Telephone

Fax

Practice Code





Urgent referral should take place in people with suspected malignancy
Referrals are supported where: Tick appropriate box indicating reason for referral

Referral for non-urgent assessment and treatment


 There is a need to assess anal skin tags
 There are underlying pathologies such as inflammatory bowel disease
 Surgery will form part of the treatment of an underlying pathology such as inflammatory bowel disease



Leeds CCGs do not routinely commission surgery for patients with anal skin tags where there is haemorrhoids, pruritis or solely a cosmetic problem.


Indicate approach taken to clinical management of the patient prior to referral:





Clinical Notes:





Past Medical History:





Drug List:





Allergies:





GP Signature:



Date:


Supporting evidence
Kuehn HG,Gebbensleben O,Hilger Y,Rohde H Relationship between anal symptoms and anal findings. International Journal of Medical Sciences, 2009; 6: 1431-42
Bonheur JL,Braunstein J,Korelitz BI,Panagopoulos G Skin tags in inflammatory bowel disease: new observations and a clinical review. Inflammatory Bowel Diseases 2008; 14; 1236-9

Review Date: April 2016



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