be expected for the average patient with that particular condition. What are likely consequences for patient if this application is not Future health • Potential use of healthcare • approved? services Financial cost to patient • What is the evidence-base for this intervention? Clinical effectiveness, 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 Delete as appropriate: No / Yes intervention part of a If Yes, give details (e.g. name of trial, is it an MRC/National clinical trial? trial?)
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, 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?)
2011.02.01%20Treatment%20Request%20Form.docx