AESTHETIC SPECIALIST PLASTIC SURGERY PROCEDURES
INFORMATION TO ACCOMPANY AN INDIVIDUAL FUNDING REQUEST (IFR) FOR BREAST REDUCTIONThe NHS does not routinely commission plastic surgery for cosmetic reasons, an NHS referral is inappropriate if the patient falls within the normal morphological range. PATIENT DETAILSNAMEDATE OF BIRTHNHS NUMBERADDRESSREFERRING GPADDITIONAL INFORMATIONWEIGHTHEIGHTBMI(taken within the last 6months)CHEST SIZECUP SIZEDo you consider your patient to be overweight? YES/NODo you consider your patient’s breast size to be in proportion to her body? YES/NO Has your patient had a professional bra measurement? YES/NODoes your patient complain of any functional problems attributable to her breast size? YES/NOHas your patient been referred to physiotherapy? YES/NOIf so, please include a copy of any reports.Have any other treatments been tried or considered? YES/NOIf YES please provide more details:GP Signature ………………………………………… Date ……………………………….. ................
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