Procedure that requires prior approval Application form: - Varicose Vein Treatment Name of Referring Clinician GP Name and Surgery Patients NHS Number Is the patient/guardian aware of the proposed treatment and have they consented to you Yes No raising this request on their behalf? Has the patient/guardian consented for their personal and clinical information to be provided Yes No to the IFR service via all means, including electronic and automated approvals, to enable full consideration of this funding request? Is this a patient/guardian led application? Yes No Most Urgent: Decision needed within a week as the patient’s life may be in danger. Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. Routine: Decision needed in 4 to 6 weeks. Prior approval is required before referral for assessment or treatment for varicose veins interventional procedures. Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration. The policy statements are available at Clinical Criteria required for consideration of treatment Please Tick Indicate which leg it is proposed to treat. (Bilateral treatment should not be requested as the 18 week pathway does not permit sufficient Left time to fully complete the surgery) Recurrent and persistent leg ulceration, secondary to chronic venous insufficiency YES NO despite 6 months of conservative management with compression stockings for the first ulcer. Please provide specific details. Significant haemorrhage from a superficial varicosity. YES NO Please provide specific clinical details Persistent and significant eczema associated with chronic venous insufficiency. YES NO Please provide specific clinical details. Lipodermatasclerosis YES NO Please provide specific clinical details. Recurrent and painful thrombophlebitis despite six months of conservative YES NO management with compression stockings. Please provide specific details. Please provide the current: YES NO Is the patient a non-smoker? YES NO
Procedure that requires prior approval Application form: - Varicose Vein Treatment Name of Referring Clinician GP Name and Surgery Patients NHS Number Is the patient/guardian aware of the proposed treatment and have they consented to you raising this request on their behalf? Yes No Has the patient/guardian consented for their personal and clinical information to be provided to the IFR service via all means, including electronic and automated approvals, to enable full consideration of this funding request? Yes No Is this a patient/guardian led application? Yes No Most Urgent: Decision needed within a week as the patient’s life may be in danger. Immediate: Decision needed within 3 weeks as delay will not be clinically appropriate. Routine: Decision needed in 4 to 6 weeks. Prior approval is required before referral for assessment or treatment for varicose veins interventional procedures. Please complete this form clearly detailing how the patient meets the criteria and email the completed form to the IFR service: for consideration. The policy statements are available at Clinical Criteria required for consideration of treatment Please Tick Indicate which leg it is proposed to treat. (Bilateral treatment should not be requested as the 18 week pathway does not permit sufficient time to fully complete the surgery) Left Recurrent and persistent leg ulceration, secondary to chronic venous insufficiency despite 6 months of conservative management with compression stockings for the first ulcer. Please provide specific details. YES NO Significant haemorrhage from a superficial varicosity. Please provide specific clinical details YES NO Persistent and significant eczema associated with chronic venous insufficiency. Please provide specific clinical details. YES NO Lipodermatasclerosis Please provide specific clinical details. YES NO Recurrent and painful thrombophlebitis despite six months of conservative management with compression stockings. Please provide specific details. YES NO Please provide the current: YES NO Is the patient a non-smoker? YES NO
Varicose-Veins-BW-v1.docx