INDIVIDUAL TREATMENT REQUEST
Complete ALL relevant details. Please type or print CLEARLY.
Date form submitted: / /
Last name: First name(s):
Gender: Male / Female Date of Birth:
2. DETAILS OF APPLYING CLINICIAN
Trust or GP Practice Name:
Last name: First name(s):
Email: We will use this email for correspondence if you are out of county – please provide
an nhs.net account.
Are you the lead clinician or GP for this person’s care?
Who made this referral to you?
3. IF SPECIALIST, DETAILS OF PATIENT’S GP
GP Name and Practice:
Is the GP aware of this request and had an opportunity for input? Yes / No
Does the GP support this request? Yes / No / Do not know
4. PATIENT CONSENT
Has the treatment been discussed with the patient? Yes / No / NA
Has the patient been placed on the waiting list? Yes / No / NA
If relevant, has a TCI date been issued? Yes / No
Patient Consent: The patient has given their consent to disclosure of Yes / No
information relevant to their case from professionals who have been involved
in their care and to the Individual Patient Treatment Team and Panel
NHS Bournemouth and Poole and NHS Dorset working together
Do you have any conflicts of interest relating to the requested treatment? Yes / No
5. TREATMENT REQUESTED
Is this request outside of NICE guidance? Yes / No / No NICE guidance
Is this request outside of licence? Yes / No / NA
If ‘Yes’ provide information on approval by Drugs and Therapeutic Committee, MDT and/or Medical
Director view on this request.
EXCEPTIONALITY: for a request outside of NICE or commissioned pathways
1. Explain why the patient is significantly different to the general population of patients with the
condition in question.
2. Explain why the patient is likely to gain significantly more benefit from the intervention than
might normally be expected for patients with that condition.
3. Are you aware of other patients for whom If ‘Yes’ detail number.
you would request treatment?
If requesting a medicine
Form and strength: Dosage to be used (include frequency):
Dosage regimen: (where applicable): Duration of treatment / number of courses:
Criteria for stopping treatment:
If requesting a Procedure / Technology
Description of procedure and modality of delivery eg inpatient:
Duration of Treatment:
Criteria for stopping treatment :
6. DISEASE / CONDITION FOR WHICH TREATMENT IS REQUESTED
In case of intervention for cancer: details of staging required and copy of MDT discussion must be attached.
In case of intervention for non cancer: What is the patient’s clinical severity? (Where possible use standard
scoring systems, e.g. WHO, DAS scores, walk test, cardiac index etc)
Alternative Treatment Options
What would be the standard treatment at this stage?
Provide a full list of relevant treatments for this condition that have been tried or considered, including dates,
reasons for stopping and response achieved:
Previous Treatment Dates started and stopped Reasons for stopping Response achieved
What is the patient’s With this treatment: Without this treatment:
What is the expected response rate for intervention requested? How will you assess an effective outcome?
Cost of treatment requested (include VAT if appropriate) to give cycle and annual cost, to detail in PbR
currencies if relevant:
7. CLINICAL EVIDENCE
Attach evidence that it is a safe and efficacious treatment: (e.g. full Attached papers:
journal articles, not just references, conference proceedings or
Note that a higher degree of proof will be required for unregistered
medications or registered medications for non-registered indications
Give details of National or Local Guidelines/
Recommendations supporting the use of this treatment:
My patient has agreed that they
If this request is considered at the Individual Patient Treatment do not want to receive a copy of
Panel the outcome will be copied to your patient. If you have
agreed with your patient that they do not want to receive a copy
letter from the Individual Patient
of the Panel letter directly please sign in this section. In doing Treatment Panel
so you are committing to communicate the outcome of a Panel Signature:
decision to your patient.
Please note that we will communicate the outcome of Team decisions which are made outside of a Panel to
you as the referrer and it will be your responsibility to liaise with your patient. Panel letters will be copied to
your patient unless you have signed above.
Address: NHS Bournemouth and Poole and NHS Dorset Cluster
Individual Patient Treatments Team
First Floor West
Dorset DT1 1TS
Email: Doremail@example.com or
Telephone: 01305 368938