Procedure that requires prior approval
Application form: - Male Circumcision
GP Name and Surgery
Patients NHS Number
Is the patient/guardian aware of the proposed treatment and have they consented to you raising this request on their behalf? / Yes ☐No ☐
Has the patient/guardian consented for their personal and clinical information to be provided to the IFR service via all means, including electronic and automated approvals, to enable full consideration of this funding request? / Yes ☐No ☐
Is this a patient/guardian led application? / Yes ☐No ☐
Most Urgent: Decision needed within a week as the patient’s life may be in danger. / ☐ /
Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. / ☐ /
Routine: Decision needed in 4 to 6 weeks. / ☐ /
Please refer your patient directly into Secondary Care as prior approval is not required for Penile malignancy or Traumatic foreskin injury where the foreskin cannot be salvaged.
Circumcision for all other indications not in the policy, including non-clinical reasons are not normally funded due to lack of national guidance and lack of good quality evidence of clinical and cost effectiveness.
Please complete the following form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration.
The policy statement is available from
Clinical Criteria required for consideration of treatment / Please Tick
- Please indicate which of the symptoms the patient has from the list below:
Where either the use of topical steroids for up to 3 months has been tried and failed
OR severe disease where a dermatologist or urologist confirms that circumcision is the only appropriate management.
☐Recurrent paraphimosiswhere the foreskin is retracted and cannot be returned back to the end of the penis using conservative measures.
☐Recurrent balanitis / balanoposthitis of more than 3 episodes per year, where hygiene measures and the use of other conservative measures, i.e. emollients, topical steroids, anti-fungals, oral antibiotics have been tried and failed.
☐A child suffering with physiological adherence of the foreskin to the penis. Please state conservative treatment tried and failed.
Please provide specific clinical information to support those selected above.
- If an adult please provide the patients current BMI:
Height / cm
Weight / kg
- Is the patient a non-smoker?
Please ensure all children who are capable of expressing a view are involved in decisions about whether they should be circumcised, and their wish taken into account. For further advice including information on parental consent, refer to: The law and ethics of male circumcision Guidance for doctors June 2006
South, Central and West Commissioning Support Unit April 2018 TVPC63 BW