Procedure that requires prior approval prior to referral Application form: - Cosmetic Surgery (Policy 1) Name of Referring Clinician GP Name and Surgery Patients NHS Number Is the patient/guardian of the proposed treatment and have they consented to you raising YES NO this request on their behalf? Has the patient/guardian consented for personal and clinical information to be provided to YES NO the IFR service 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 as delay will not be clinically appropriate. Routine: Decision needed in 4 to 6 weeks. Where there is a suspicion of malignancy and the patient has been referred on the 2 week wait pathway then application to the IFR service is not appropriate. This form includes Aesthetic or Cosmetic Surgery for Adults and Children including but not limited to, abnormally placed hair and hirsutism, male pattern baldness, alopecia, bat/prominent ears, repair of earlobes (external ear), scars including keloid (removal and revision), tattoo (removal and revision) and other requests not covered by a specific form. Please note that unless the patient fully meets the criteria and there are exceptional health needs clearly demonstrated in the form which are deemed acceptable by the panel, it is unlikely that funding will be approved. 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 What is the procedure being requested? Abnormally placed hair/ hirsutism Male pattern baldness Alopecia Bat/ prominent ears Repair of earlobes (external ear) Scar removal and revision (including keloid) – Tattoo (removal or revision) Other. Please specify: For which part of the body is the procedure required? Please provide details and clearly indicate if multiple areas are to be treated. Is there an underlying congenital condition? Please provide details: Please provide details of all treatments already received for the same condition: Abnormally placed hair and hirsutism Please tick which of the following apply: Hair is on the face
Procedure that requires prior approval prior to referral Application form: - Cosmetic Surgery (Policy 1) Name of Referring Clinician GP Name and Surgery Patients NHS Number Is the patient/guardian of the proposed treatment and have they consented to you raising this request on their behalf? YES NO Has the patient/guardian consented for personal and clinical information to be provided to the IFR service 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 as delay will not be clinically appropriate. Routine: Decision needed in 4 to 6 weeks. Where there is a suspicion of malignancy and the patient has been referred on the 2 week wait pathway then application to the IFR service is not appropriate. This form includes Aesthetic or Cosmetic Surgery for Adults and Children including but not limited to, abnormally placed hair and hirsutism, male pattern baldness, alopecia, bat/prominent ears, repair of earlobes (external ear), scars including keloid (removal and revision), tattoo (removal and revision) and other requests not covered by a specific form. Please note that unless the patient fully meets the criteria and there are exceptional health needs clearly demonstrated in the form which are deemed acceptable by the panel, it is unlikely that funding will be approved. 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 What is the procedure being requested? Abnormally placed hair/ hirsutism Male pattern baldness Alopecia Bat/ prominent ears Repair of earlobes (external ear) Scar – removal and revision (including keloid) Tattoo (removal or revision) Other. Please specify: For which part of the body is the procedure required? Please provide details and clearly indicate if multiple areas are to be treated. Is there an underlying congenital condition? Please provide details: Please provide details of all treatments already received for the same condition: Abnormally placed hair and hirsutism Please tick which of the following apply: Hair is on the face
Cosmetic-Surgery-January-2018-BD.docx