Procedure that requires prior approval Application form: - Management of asymptomatic gallstones Name of Referring Clinician GP Name and Surgery Patient NHS Number Is the patient/guardian aware of the proposed treatment and have they consented to you Yes No raising this request on their behalf? Has the patient/guardian consented for their personal and clinical information to be provided Yes No to the IFR service via all means, including electronic and automated approvals, to enable full consideration of this funding request? Is this a patient/guardian led application? Yes No Most Urgent: Decision needed within a week as the be in danger. patient’s life may Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. Routine: Decision needed in 4 to 6 weeks. Thames Valley Priorities Committee supports cholecystectomy as per NICE Clinical Guideline CG188 Gallstone disease: diagnosis and management: Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration. The policy statements are available at . Please complete the following sections in full. Incomplete applications will not be considered and will be returned. Clinical Criteria required for consideration for treatment Please tick or delete as appropriate Has the patient stones that were found incidentally, as a result of YES NO imaging investigations unrelated to gallstone disease and have been completely symptom free for at least 12 months before diagnosis? Has the patient symptomatic stones found on gallbladder imaging, YES NO regardless of whether symptoms are being experienced currently or whether they occurred sometime in the 12 months before diagnosis? If an adult, the Body Mass Index: patient’s Is the patient a non-smoker? YES NO If No, has the patient been referred to smoking cessation service? Yes No SIGNATURE OF CLINICIAN ……………………………………………………………. DATE: …………………………………………………..
Procedure that requires prior approval Application form: - Management of asymptomatic gallstones Name of Referring Clinician GP Name and Surgery Patient 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. Thames Valley Priorities Committee supports cholecystectomy as per NICE Clinical Guideline CG188 Gallstone disease: diagnosis and management: Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration. The policy statements are available at . Please complete the following sections in full. Incomplete applications will not be considered and will be returned. Clinical Criteria required for consideration for treatment Please tick or delete as appropriate Has the patient stones that were found incidentally, as a result of imaging investigations unrelated to gallstone disease and have been completely symptom free for at least 12 months before diagnosis? YES NO Has the patient symptomatic stones found on gallbladder imaging, regardless of whether symptoms are being experienced currently or whether they occurred sometime in the 12 months before diagnosis? YES NO If an adult, the patient’s Body Mass Index: Is the patient a non-smoker? If No, has the patient been referred to smoking cessation service? Yes No YES NO SIGNATURE OF CLINICIAN ……………………………………………………………. DATE: …………………………………………………..