Patient Consent By submitting this request you are confirming that you have fully explained to the patient the proposed treatment and they
have consented to you raising this request on their behalf.
Is the patient aware of this referral and the contents of this form and supporting documents? YES NO
I confirm that the patient consents to the CCG IFR Team accessing personal clinical information about them that is YES NO
held by IFR staff to enable full consideration of this funding request?
Please complete the following sections in full. Incomplete applications will not be considered and will
be returned.
Clinical Criteria required for consideration for treatment Please tick and add details and dates
where requested
1. Does the patient suffer with ongoing pain which significantly
YES NO
interferes with activities of daily living.
South, Central and West Commissioning Support Unit October 2015 PLEASE TURN OVER
4. Is it an inguino-scrotal hernia?
YES NO
6. What are the significant symptoms and how long has the patient noticed the hernia?
10. Exceptional circumstances may be considered where the patient’s capacity to benefit from that treatment is likely
to be different to that of other patients with the same condition because they are reasonably expected to obtain a
significantly better clinical outcome from that treatment than would be expected from other similar patients.