Gamma Knife Referral Form

Please note that all fields are mandatory, and imaging should be sent separately by image link from the referring hospital to Leeds Teaching Hospitals.

Gamma Knife Referral

Section A – Patient Details

First name(Required)

Last name(Required)

Address(Required)

Street Address Address Line 2 City Post code

Date(Required)

NHS Number(Required)

Patient's current location(Required)

If Home please provide their contact phone number below if known

Patient's telephone number(Required)

GP name(Required)

GP Address(Required)

Street Address Address Line 2 City Post code

Referring hospital(Required)

Referring Doctor(Required)

Consultant(Required)

Specialty(Required)

Consultant telephone number(Required)

Consultant GMC number(Required)

Section B – Referral Information

Referral diagnosis(Required)

History of illness(Required)

Please include details of symptoms of raised ICP, specific neurological deficits and seizures

Past history(Required)

Please include details of comorbid conditions, bleeding tendencies and any prior treatment

Current Medications(Required)

WHO Performance Status(Required)

Imaging(Required)

Please include type of scan – CT/MRI, date of investigation, and location of scans. Imaging should be sent by image link from the referring hospital to Leeds Teaching Hospitals NHS Trust. Our contact number for questions is 0113 2067751

Summary of findings(Required)