AESTHETIC SPECIALIST PLASTIC SURGERY PROCEDURES
INFORMATION TO ACCOMPANY AN INDIVIDUAL FUNDING REQUEST (IFR) FOR BREAST AUGMENTATIONThe 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 6 months)CHEST SIZECUP SIZEIn your opinion does the patient have breast agenesis? Yes/No Has your patient had a professional bra measurement? Yes/NoPlease provide any other relevant information in support of your request:GP Signature ………………………………………… Date ……………………………….. ................
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