Request for Female Breast Surgery

Patient Information

NHS Number / DOB
Full Name / Contact Number
Address
Procedure / Reduction Asymmetry (circle as necessary)
Patient choice of provider for carrying out procedure
(If not UHL, please check option is available through Choose & Book) / UHL 
Other ………………………………..
(Please state)
The patients current BMI is:
The patient is currently a non smoker
The current BMI measurement is >= 18.0 and <= 25.0 and has been measured, recorded by the NHS and maintained for the previous 12 months

Please do not refer a patient to the Cosmetic Review Panel unless all the criteria have been ticked. Please attach a print out of the patient’s active medical problems, significant past medical history and medication list.

Where the GP has confirmed that all the above criteria are being met the CCG will forward the patient details to Body Aspects Ltd for a 3D body scan. The body scan report will establish the remaining policy criteria. Body aspects Ltd will contact the patient direct to arrange an appointment. Any delay in the patient attending will delay a final funding decision by the CCG.

I confirm that this Funding Request has been discussed in full with the patient and it would / would not be appropriate (please delete as necessary) for the patient to be copied into all correspondence. The patient is aware that they are consenting for the Funding Request Team to access confidential clinical information held by clinical staff involved with their care about them as a patient to enable full consideration of this funding request. Please note LLR CCGs are under obligation to let the patient know the outcome of all funding applications. Where the patient has requested the funding submission, it is good practice to ask the patient if they wish to be copied into other correspondence between the clinician and the CCGs. Where the patient has not made the request, the patient should be copied into other correspondence between the clinician and the CCGs unless it is clinically inappropriate to do so.

GP Name______

Practice Name/ Address______

GP Signature______Date______

Please return this form electronically via secure email: or hard copy to: The Cosmetic Surgery Request Officer, East Leicestershire and Rutland Clinical Commissioning Group, Unit 2-3 (Ground Floor), Bridge Park Industrial Estate, 674 Melton Road, Thurmaston, Leicestershire, LE4 8BL