PRIOR APPROVAL FORM

MANAGEMENT OF HYPERHIDROSIS: BOTULINUM TOXIN

To enable the application to be considered fully please provide supporting information to evidence assessment in the free text area or attach supporting information such as clinic letter. Email form to ifr.mk@nhs.net

PART A – MUST BE COMPLETED FOR ALL REQUESTS

Patient Information
Name:
Title:
Address:
DoB:
NHS No:
Home Tel No:
Mobile Tel No:
Information obtained from carer/patient representative1?	Yes
No

Consultant Information
Name:
Address:
Tel No:
NHS net email address:
Date form completed:

Requesting Clinician – please confirm the following:
Patient Consent: The patient or patient representative hereby gives consent for disclosure of information relevant to their case to the CCG commissioned IFR Team.	Yes
No
I have informed the patient or patient representative1 that this intervention will only be funded where the criteria are met and approval has been given.	Yes
No
I confirm that I have reviewed the patient against the commissioning criteria and that the information provided within this application is accurate.	Yes
No
I confirm that I have explained to the patient the procedure being requested for and can confirm that the patient is willing to undergo this invention if the funding request is approved.	Yes
No

PART B – ELIGIBILITY MUST BE COMPLETED FOR ALL REQUESTS

Policy Statement

Treatments which are undertaken without approval will not be funded.

To reduce smoking and obesity in all pre-operative patients, with the consequence of fewer complications and better patient outcomes:

Smokers should be referred to a smoking cessation course before being referred to a first outpatient appointment that is likely to result in an operation

People who have a body mass index of 35 or above should be referred to a weight management programme.

If smoking cessation and weight management courses have not been offered, the referrer should consider, along with the patient, how a smoking and/or weight management course could improve the patient’s health.

Is the patient a current smoker?	Yes
No
If YES, has the patient undertaken a smoking cessation course?	Yes
No
Is the patient’s BMI above 35?	Yes
No

Eligibility Criteria
Please indicate the hyperhidrosis condition:	Yes
No
Axillary	Craniofacial
Palmar/plantar
AND Have conservative measures including high strength antiperspirants and topical aluminium chloride have failed (please refer to policy)?	Yes
No
AND Does the patient have a HDSS score of 4?	Yes
No
AND Have the symptoms lasted for at least 3 months?	Yes
No

Please provide evidence below to support the information provided. Without evidence your application may be rejected. If you prefer you can attach supporting information, such as a clinic letter, rather than completing the box below.

Supporting information:

This means a person with legal authority to take decisions about medical care and treatment on behalf of the patient, on the basis that they lack capacity to take these decisions themselves. The source of that legal authority should be clearly identified.

V0.2 June 18

ITC-JG

2019-04-02

Dupe Fagbenro

Gloucestershire NHS Trusts