No prior treatment with idelalisib Note: Patients receiving Ibrutinib via the compassionate use programme should not be switched to CDF funding. Free of charge supplies from the manufacturer should continue to be used in these patients until NICE approval and as per the terms of the compassionate use programme 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 birth* Hospital No: Optional Hospital No. – Clinical Commissioning CCG Name: Group* Patient’s GP* Name: (name, address, Address: telephone) Post Code: ICD-10 Code* C91.1 – Chronic lymphocytic leukaemia of B-cell type HRG Code Completion of items marked with * is mandatory. Failure to complete these items may mean that payment is not made.
No prior treatment with idelalisib Note: Patients receiving Ibrutinib via the compassionate use programme should not be switched to CDF funding. Free of charge supplies from the manufacturer should continue to be used in these patients until NICE approval and as per the terms of the compassionate use programme 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 birth* 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* C91.1 – Chronic lymphocytic leukaemia of B-cell type HRG Code Completion of items marked with * is mandatory. Failure to complete these items may mean that payment is not made.
IBR1_v1.1_Ibrutinib_relapsedrefractory_CLL.docx