STH Neuro Skull Base MDT Referral Form

The Skull Base MDT is held fortnightly on Monday's. Urgent opinions can be sought from the on-call team at other times.

If there are issues with this electronic form, paper-based referrals can still be made using the referral form emailed to sth.SkullBaseMDTReferrals@nhs.net.

– Referrer Information

Referring Consultant (Required)

Consultant's Email Address (nhs.net emails only) (Required)

Referring Speciality (Required)

Hospital (Required)

Referrer's Name (Required)

Referrer's Email Address (nhs.net emails only) (Required)

Referrer's Contact Phone Number for Referral Queries (Required)

Email Address for MDT Outcome (only provide a single, valid nhs.net email address) (Required)

+ Patient Details

Patient Name (Required)

Patient Date of Birth (Required)

NHS Number

Gender (Required)

Patient's Home Address (Required)

Patient Type (Required)

+ Pathology

Patient History/Presenting Symptoms (Required) (maximum 500 characters)

Question To MDT (Required) (maximum 500 characters)

WHO Performance Status (grade most appropriate) (Required)

Previous Histology Details (including date and lab) (Required) (maximum 500 characters)

Confirmation that patient is aware that the MDT may contact them urgently (Required)

+ Imaging

Imaging Hospital

MRI Performed (Required)

MRI Date

Please Confirm the MRI Has Been Transferred to STH

CT Performed (Required)

CT Date

Please Confirm the CT Has Been Sent to STH PACS

+ Other

Attachments

Upload additional documents (PDF or Word, up to 5 files)

Drag & drop files here or click to select

You can upload up to 5 files. Max size: 10MB per file.