Has the patient any living children? This includes a child adopted YES NO by the patient. Is the patient a post-pubertal male YES NO Is the patient a post-pubertal, pre-menopausal female under the YES NO age of 35 years Please confirm the patient prior for referral for cryopreservation, has been screen for : YES NO HIV Hepatitis B YES NO Hepatitis C YES NO Has the patient been screened for any other relevant infectious YES NO disease prior to referral for cryopreservation Please provide details Does the patient have a Body Mass Index (BMI) of 27 (Female) / YES NO 25 (Male) or less for at least 2 years before surgery? Please state the patient’s BMI: BMI Height: Height Weight Weight: Is the patient a non-smoker? YES NO Exceptional health need: Please provide details SIGNATURE OF CLINICIAN ……………………………………………………………. DATE: ………………………………………………….. Exceptional Status (what makes the individual sufficiently different from the in policy terms). Central to consideration of individual ‘usual’ requests for funding is the concept of the case being exceptional. In order for funding to be agreed there must be unusual or unique clinical factors about the patient that suggest that they are: Significantly different to the general population of patients with the condition in question and likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition. However: The fact that a treatment is likely to be efficacious for a patient is not, in itself, a basis for an exception. If a patient's clinical condition matches the 'accepted indications' for a treatment that is not funded, their circumstances are not, by definition, exceptional. of patients) are not relevant to the consideration of exceptional status but there may rarely be Social value judgments (the 'worth’ exceptional circumstances where benefits may go beyond the patient (e.g. as a carer) in respect of social or health related benefits for others. Please email the completed form to for consideration.
Has the patient any living children? This includes a child adopted by the patient. YES NO Is the patient a post-pubertal male YES NO Is the patient a post-pubertal, pre-menopausal female under the age of 35 years YES NO Please confirm the patient prior for referral for cryopreservation, has been screen for : HIV Hepatitis B Hepatitis C YES NO YES NO YES NO Has the patient been screened for any other relevant infectious disease prior to referral for cryopreservation Please provide details YES NO Does the patient have a Body Mass Index (BMI) of 27 (Female) / 25 (Male) or less for at least 2 years before surgery? Please state the patient’s BMI Height Weight YES NO BMI: Height: Weight: Is the patient a non-smoker? YES NO Exceptional health need: Please provide details SIGNATURE OF CLINICIAN ……………………………………………………………. DATE: ………………………………………………….. Exceptional Status (what makes the individual sufficiently different from the ‘usual’ in policy terms). Central to consideration of individual requests for funding is the concept of the case being exceptional. In order for funding to be agreed there must be unusual or unique clinical factors about the patient that suggest that they are: Significantly different to the general population of patients with the condition in question and likely to gain significantly more benefit from the intervention than might be expected from the average patient with the condition. However: The fact that a treatment is likely to be efficacious for a patient is not, in itself, a basis for an exception. If a patient's clinical condition matches the 'accepted indications' for a treatment that is not funded, their circumstances are not, by definition, exceptional. Social value judgments (the 'worth’ of patients) are not relevant to the consideration of exceptional status but there may rarely be exceptional circumstances where benefits may go beyond the patient (e.g. as a carer) in respect of social or health related benefits for others. Please email the completed form to for consideration.
Preservation-of-fertility-Nov-2015-BU.docx