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TREATMENT REQUEST FORM Section A – patient and referring clinician details Patient details Surname Referring clinician details Applicant Name Forename(s) Contact / Email Address and Post Code Practice Address and Post Code Date of Birth GP Name & Contact Details, if not the referrer NHS No. Gender Entitled to NHS treatment? Yes / No Is the Patient aware that this approval request has been made to the PCT? Date Received (PCT Use) YES / NO Has the patient received a copy of all the information forwarded to the PCT? Patient Initials (PCT Use) YES/NO Section B – please complete for ALL requests Patient Diagnosis / Issue Details of intervention requested: Specify: Provider Procedure Course of treatment Trial Other What are the exceptional circumstances? Definition of exceptionality: He/she is different to the general population of patients who would normally be refused the health care intervention AND there are good grounds to believe the patient is likely to gain significantly more benefit from the intervention than might be expected for the average patient with that particular condition. What are likely consequences for patient if this application is not approved? • Future health • Potential use of healthcare services • Financial cost to patient What is the evidence-base for this intervention? Clinical effectiveness, costeffectiveness; Assessments / publications by advisory bodies (please attach) Has patient been seen by a local consultant, if appropriate? If not, why are local services not sufficient? Please indicate cost of proposed treatment: Where possible Section C – Please complete for requests for drug treatments Further details of intervention (for which approval is requested) Dose and frequency Planned duration Of intervention Exit strategy / stopping criteria (e.g. disease progression, poor response, adverse events) Route of administration Anticipated cost (inc VAT) – seek advice from pharmacy Is requested intervention part of a clinical trial? Delete as appropriate: No / Yes If Yes, give details (e.g. name of trial, is it an MRC/National trial?) What would be the standard intervention at this stage (including cost)? What are the exceptional circumstances that make the standard intervention inappropriate for this patient? In case of intervention for cancer: What is disease status? (eg. at presentation,1st, 2nd or 3rd relapse) What is the WHO performance status? How advanced is the cancer? (stage) Describe any metastases: In case of intervention for noncancer: What is the patient’s clinical severity? (Where possible use standard scoring systems e.g. WHO, DAS scores, walk test, cardiac index etc.) Summary of previous intervention(s) this patient has received for the condition. Dates Intervention (e.g. drug / surgery) * e.g. Course completed / No or poor response / Disease progression / Adverse effects or poorly tolerated Anticipated start date Processing requests can take up to 2 weeks (from the date received by the PCT). If the case is more urgent than this, please state why: PLEASE CONTINUE ON A SEPARATE SHEET IF NECESSARY Please send completed form and accompanying documents to: Mrs Janet Wade Senior Nurse Case Manager NHS Rotherham Oak House Rotherham S66 1YY Reason for stopping* / Response achieved