b. Indicate below the PS of the patient at the time of completing this form: i. 0 ii. 1 At time of starting osimertinib, the patient must be fit enough to have potentially started platinum-based doublet chemotherapy Please document the date of expected start of treatment with osimertinib Consultant Approval (email authority) Patient Consent Obtained (date of letter copy to be retained on patient file) – Proposed Start Date for Therapy (add clinic date)*: Consultant details* Name: (including signature or Hospital: email confirmation) Address: Post Code: Telephone: Nhs.net Trust Pharmacist - Name: details of the Trust where Hospital: the patient will be Address: treated* Post Code: Telephone: Nhs.net Mandatory - NHS No*: NHS No: Mandatory Patients – DOB: date of Hospital No: Optional Hospital No. – Clinical Commissioning CCG Name: Group* Patient’s GP* Name: (name, address, Address: telephone) Post Code: ICD-10 Code* C34 Malignant neoplasm of bronchus & lung – HRG Code Completion of items marked with * is mandatory. Failure to complete these items may mean that payment is not made.
b. Indicate below the PS of the patient at the time of completing this form: i. 0 ii. 1 At time of starting osimertinib, the patient must be fit enough to have potentially started platinum-based doublet chemotherapy Please document the date of expected start of treatment with osimertinib Consultant Approval (email authority) Patient Consent Obtained (date of letter – copy to be retained on patient file) Proposed Start Date for Therapy (add clinic date)*: Consultant details* (including signature or email confirmation) Name: Hospital: Address: Post Code: Telephone: Nhs.net Trust Pharmacist - details of the Trust where the patient will be treated* Name: Hospital: Address: Post Code: Telephone: Nhs.net Mandatory - NHS No*: Mandatory – Patients date of Optional – Hospital No. NHS No: DOB: Hospital No: Clinical Commissioning Group* CCG Name: Patient’s GP* (name, address, telephone) Name: Address: Post Code: ICD-10 Code* C34 – Malignant neoplasm of bronchus & lung HRG Code Completion of items marked with * is mandatory. Failure to complete these items may mean that payment is not made.
OSI1_v1.0_Osimertinib_NSCLC.docx