To be used by Primary care Providers only
Patient’s Name: / Patient's Date of Birth:Has patient given consent for this information to be shared with IFR TeamYES / NO
NHS Number: / Date of Referral to PCT:
Ethnicity (see over)
please specify: / Patient’s Address (including Postcode):
Referrer’s Details :
Tel No.
GP Name:
Tel No.
Treatment requested / If Relevant
PHQ9/GAD7(attached)
BMI ......
Further information attached
Will this procedure only result in a change in the patient’s appearance?
Yes
What is the rationale for the request?
Please include any available evidence on clinical and cost effectiveness
Please refer to NHS Suffolk’s Individual Funding request policy. State in detail the exceptionality in this particular patient.
Is there any routine alternative treatment available?
Cost: (if known)
Please indicate the basis for urgency: - tick as appropriate
Urgent – Decision within a week as patient’s clinical circumstances may warrant an urgent decision
Immediate – Decision needed within 3 weeks as delay will not be clinically appropriate
Routine – Decision needed in 4 to 6 weeks
Signed:………………………………….Name in capitals……………………………………………….
Tel No: ………………………………….Practice…………………………………….Date………….….
Fax No: ......
Forms must be completed by GP or Clinician and should to be returned to:
IFR Manager, NHS Suffolk, Rushbrook House, Paper Mill Lane, Bramford, Ipswich IP8 DE
Tel: 01473 770068/770170 Fax: 01473 832511or email:
Please select from one of the following 16 groups:
White
1 = British
2 = Irish
3 = Any other white background, please specify
Mixed
4 = White and Black Caribbean
5 = White and Black African
6 = White and Asian
7 = Any other Mixed background, please specify
Asian or Asian British
8 = Indian
9 = Pakistani
10 = Bangladeshi
11 = Any other Asian background, please specify
Black or Black British
12 = Caribbean
13 = African
14 = Any other Black background, please specify
Chinese or other ethnic group
15 = Chinese
16 = Any other, please specify
Revised:July 2013Review:July 2014
This consent will be used for invoice validation