We are unable to process requests that contain any patient identifiable information. Please do not include anywhere on the form, nor attachments, any patient identifiable information. This includes anything that may refer to, or identifies, the patient’s name, address, nhs/clincial system reference numbers, details of relatives, carers or those they are guardians for.

The onus lies with the requesting clinician to present a full submission to the IFR Team which sets out a comprehensive and balanced clinical picture of the history and present state of the patient’s medical condition, the nature of the treatment requested and the anticipated benefits of the treatment.

All necessary information including research papers must be submitted with this form.

 

Requests can only be considered based on the information provided.

 

Incomplete forms providing insufficient information will not be considered.

 

Any documents uploaded MUST BE redacted to ensure no personal identifiable information is included.

 

Note: if you wish to upload copies of relevant clinical research to support your request, please have them ready before starting to complete this form. You are unable to save this form and your browser may time out and you will lose any information entered.