Medical Intervention Form

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Step 1

Medical lead name (required)

Medical lead email address (required)

Associated facility and commercial manager

Are any other hospital(s)/clinic(s) involved?

Describe the intervention (required)

Patient selection criteria (required)

Treatment protocols

Anticipated number of patients per year 0 20

What are the benefits of this intervention? (required)

What are the risks of this intervention? (required)

Does any aspect of treatment involve sites outside the UK (hospital, laboratory etc.)

Name(s) of clinician(s) providing the treatment

Medical Advisory Committee (MAC) approval status

What NICE guidance applies? Use with standard arrangements for clinical governance consent and audit Use with special arrangements for clinical governance consent and audit Use only in research Do not use No NICE guidance published

Link to NICE guidance

If NICE guidance is imminent, please give details here

Additional licensing details

Provider Information Centre

Funding safe & effective care

Request funding for a medical intervention

Step 1

Step 2