Patient Consent Obtained (date of letter copy to be retained on patient file) – Proposed Start Date for Therapy (add clinic date)*: Consultant details* Name: (including signature or Hospital: email 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* C61 Malignant neoplasm of prostate – HRG Code Completion of items marked with * is mandatory. Failure to complete these items may mean that payment is not made.
Patient Consent Obtained (date of letter – copy to be retained on patient file) Proposed Start Date for Therapy (add clinic date)*: Consultant details* (including signature or email 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* C61 – Malignant neoplasm of prostate HRG Code Completion of items marked with * is mandatory. Failure to complete these items may mean that payment is not made.
ABI1_ver2.1_Abiraterone_CRPC.docx