NHS North Derbyshire and NHS Hardwick CCG PLCV Referral Form Tonsillectomy and/or adenoidectomy THIS FORM MUST BE COMPLETED IN FULL AND SUBMITTED WITH THE APPROPRIATE CLINICAL INFORMATION Patient details Referring GP details Surname Referring GP Forename(s) Practice name Address Practice address Post code Post code Date of birth Telephone number NHS Number GP practice code Part A - PLCV Criteria/declaration for Tonsillectomy and/or adenoidectomy At least The CCG will fund tonsillectomy for indications A or B in adults or children. It will fund ONE must tonsillectomy for indication C in children only. apply Note:- For suspected malignancy using a 2 week wait referral form A: More than one episode of peri-tonsillar abscess (quinsy). A: Acute upper airways obstruction. B: Recurrent sore throat criteria 1 and 2 (below) both apply and the principal cause is tonsillitis: At least Criteria 1 ONE must apply 7 or more eligible episodes in the last year. 5 or more eligible episodes in each of the last 2 years. 3 or more eligible episodes in each of the last 3 years. NB. An episode” must have three of the following criteria [Centor Clinical Prediction score]: “eligible Tonsillar exudates. Tender anterior cervical nodes. History of fever (>38 C). Absence of cough. Criteria 2 Must apply A significant and documented impact on quality of life e.g. absence from school/ work.
NHS North Derbyshire and NHS Hardwick CCG PLCV Referral Form Tonsillectomy and/or adenoidectomy THIS FORM MUST BE COMPLETED IN FULL AND SUBMITTED WITH THE APPROPRIATE CLINICAL INFORMATION Patient details Referring GP details Surname Referring GP Forename(s) Practice name Address Post code Practice address Post code Date of birth Telephone number NHS Number GP practice code Part A - PLCV Criteria/declaration for Tonsillectomy and/or adenoidectomy The CCG will fund tonsillectomy for indications A or B in adults or children. It will fund tonsillectomy for indication C in children only. Note:- For suspected malignancy using a 2 week wait referral form At least ONE must apply A: More than one episode of peri-tonsillar abscess (quinsy). A: Acute upper airways obstruction. B: Recurrent sore throat criteria 1 and 2 (below) both apply and the principal cause is tonsillitis: Criteria 1 At least ONE must apply 7 or more eligible episodes in the last year. 5 or more eligible episodes in each of the last 2 years. 3 or more eligible episodes in each of the last 3 years. NB. An “eligible episode” must have three of the following criteria [Centor Clinical Prediction score]: Tonsillar exudates. Tender anterior cervical nodes. History of fever (>38 C). Absence of cough. Criteria 2 Must apply A significant and documented impact on quality of life e.g. absence from school/ work.
Tonsillectomy_and_or_adenoidectomy_v2_with_part_b_amends.docx