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East Midlands Cancer Drug Fund (EMCDF)
Application for Arsenic Trioxide for Relapsed APML
PATIENT PERSONAL DETAILS
Patient Name:
Date of Birth:
NHS Number:
Primary Care Trust:
GP Name & Practice Details:
Please note that all personal information will be removed prior to the consideration by the
EMCDF panel
DETAILS OF REQUESTER
(include referring clinician contact details in the event of query or need for clarification)
Name:
Designation:
Trust:
Contact phone
number:
Secure email for correspondence:
Provider Trust Chemotherapy Lead
 Yes
 No
(or equivalent) Support:
Name of Trust Chemotherapy Lead
(or equivalent):
CLINICAL DETAILS
ECOG Performance status
Disease refractory to or relapsed following first line
chemotherapy






0
1
2
3
Yes
No
CONSENT
I confirm that this Request has been discussed in full with the patient and that the patient is
aware that they are consenting for the Cancer Drugs Fund Panel 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
Signature of Requester:
Date:
MONITORING RESPONSE
How will the benefits of the procedure/treatment be measured?
(incl. frequency of assessments)
What ‘stopping’ criteria will be in place to decide when the treatment is ineffective?
Please note that regular updates on response to treatment may be requested by the Cancer
Drugs Fund Panel and/or EMSCG
E-mail completed application forms to [email protected]
Document Code: EMCN-DC-0004-10 v2
Written By: Colin Ward
Date of Reissue: July 2012
Authorised By: EMCDAG/WG.CC.CW.MQ
Review Date: July 14
Page Number: 1of 1