Consultant details* Name: (including signature or Hospital: confirmation) Address: Post Code: Telephone: Nhs.net Trust Pharmacist - Name: details of the Trust where Hospital: the patient will be Address: treated* Post Code: Telephone: Nhs.net Mandatory - NHS No*: NHS No: Mandatory Patients – DOB: date of birth* Hospital No: Optional Hospital No. – Clinical Commissioning CCG Name: Group* Patient’s GP* Name: (name, address, Address: telephone) Post Code: ICD-10 Code (please tick C18 - Malignant neoplasm of colon the relevant box)* C19 - Malignant neoplasm of rectosigmoid junction C20 - Malignant neoplasm of rectum HRG Code Completion of items marked with * is mandatory. Failure to complete these items may mean that payment is not made.
Consultant details* (including signature or confirmation) Name: Hospital: Address: Post Code: Telephone: Nhs.net Trust Pharmacist - details of the Trust where the patient will be treated* Name: Hospital: Address: Post Code: Telephone: Nhs.net Mandatory - NHS No*: Mandatory – Patients date of birth* Optional – Hospital No. NHS No: DOB: Hospital No: Clinical Commissioning Group* CCG Name: Patient’s GP* (name, address, telephone) Name: Address: Post Code: ICD-10 Code (please tick the relevant box)* C18 - Malignant neoplasm of colon C19 - Malignant neoplasm of rectosigmoid junction C20 - Malignant neoplasm of rectum HRG Code Completion of items marked with * is mandatory. Failure to complete these items may mean that payment is not made.
CET2_v4.0_Cetuximab_2nd3rdmCRC.docx