October 2010 Document Reference Number Version 7.0 – October 2010 – kt Previous Document Number Version 6.0 – August 2010 – nh Policy developed by Sarah Dugan, Director of Strategy & Innovation – Executive Nurse Dr Steve Cartwright, GP and Chair of Professional Committee Dr Sandra Brindley, GP and PEC Member Denise Bell, Exceptional Treatment Requests Manager Mike Shaw, Non-Executive Director Bryan Richens, Non-Executive Director Alison Tennant, Specialist in Pharmaceutical Public Health Alan Head of Contracting Dawn Williams, Head of Mental Health Commissioning Dr David Hegarty, GP and PEC Member Duncan Jenkins, Specialist in Pharmaceutical Public Health M Senior Contracts Manager Policy reviewed by Sarah Dugan, Chair and Director of Strategy & Innovation – Executive Nurse Denise Bell, Exceptional Treatment Requests (ETR) Manager Dr. S. Brindley, GP Dr. S. Cartwright, GP and PEC Chair Dr. P.D. Gupta, GP Dr. T. Horsburgh, GP Alan Head of Contracting Mike Shaw, Non Executive Director Alison Tennant, Specialist in Pharmaceutical Public Health Adam Pickles, Consultant Clinical Psychologist, Mental Health Services, Dudley & Walsall Mental Health Trust Sara Shreeve, Consultant Clinical Psychologist in Physical Health Psychology, Dudley PCT Individuals consulted Mr. Mehboob Ali, Plastic Surgeon and Clinical Lead for Plastic Surgery Mr. Simon Wharton, Paediatric and Adult Plastic Surgeon Consultant Plastic Surgeons Dr. Stewart, Consultant Dermatologist all from Dudley Group of Hospitals NHS Foundation Trust All PBC Cluster Chairs, NHS Dudley August/September/October 2010 Policy update: Individuals Consulted Dr Mann – Planned Care Clinical Lead, Dudley PCT Dr Stephen Cartwright – PEC Chair, Dudley PCT Dr David Hegarty – Urgent Care Lead / ENT lead for Dudley PCT Dr Paul Harrison – Medical Director, DGoH Dr Dave Perks – Clinical Director, DGOH Mr Paul Stonelake – Consultant Surgeon General Surgery, DGoH
Date/time of Details of Patient Full Name Date of Birth NHS Number Address Tel. No. Description of Image I consent to the attached images being supplied to NHS Dudley for processing my application for treatment. Signed:________________________________ Date:______________________ If under 16 years old consent of parent/guardian is also required Signed:________________________________ Date:______________________ NHS Dudley may store supplied image and the information supplied on this form, you have a right to see a copy of the information held about you on application to the Associate Director of Governance. The Trust’s Associate Director of Governance can be contacted on 01384 322050 or via Email at . Further information relating to the Data Protection Act 1998 can be found on the Information Commissioner’s website at Disclaimer: All patient identifiable information, including data held electronically, clinical records, photographs and audio tapes will be stored in line with the Trust Records Management Policy. Furthermore, patient information will not be held for longer than is necessary, and will be ultimately destroyed in a confidential manner in line with our Trust Retention Schedule. A copy of the Trust Health Records Policy and the Trust Retention and Disposal Policy can be found Appendix 2 Breast Augmentation Guidelines If the patient meets with the breast augmentation criteria, the following information will be required by the NHS Dudley Exceptional Treatment Approval Panel in order to reach a fully informed and fair decision about the individual patient request.