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|Patient Demographics |

|Patient Name |      |

|Patient Address |      |

|Date of Birth |      |

|Diagnosis |      |MRN |      |

|Referring Hospital |      |Referring Consultant |      |

|Insurance |Public Private |Insurance Details |      |

|Treatment Details |

|Treatment Site |      |Laterality |      |Lobe |      |

|Previous Radiotherapy Treatment Details |

|Previous RT |Yes No |Site |      |Dose |      |

|Details Included |Yes No N/A |Centre |      |

|Information Required for SABR Referral |

|Histology |

|Pathology/ Cytology report | |Reason:       |

|Correspondence |

|Referral letters/ correspondence / documents | |

|Lung MDT report/ pro-format | |Comment:       |

|Correspondence from surgical review | |Reason:       |

|Work-Up |

|PFTs Report - within 6 months of referral | |Reason:       |

| | |Date if not within 6 months:       |

|EBUS Report (if completed) | |Reason:       |

|Recent Blood Results | |Reason:       |

|Imaging – must be dated within 12 weeks of referral |

|FDG Avid Lesions |

|PET Scan (whole body) report | |Reason:       |

|PET Scan (whole body) images | |Reason:       |

|FDG Non Avid Lesions |

|CT TAP report | |Reason:       |

|CT TAP images | |Reason:       |

|Medical History |Details |

|Co-morbidities/ Special Requirements |      |

|General Comments |      |

Send completed referral form and associated reports/ documents to sabr.referrals@slh.ie

Receipt of referral will be acknowledged in writing. Referrals will only be processed once all relevant requested information is received.

Send CT & PET images (discs) to MDT Coordinator, St Luke’s Radiation Oncology Centre, St James’ Hospital, James’ St., Dublin 8. Please ensure they are labelled with patient name, date of birth and MRN.

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