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