FORM FRM4906/1.1
Effective: 17/02/15
Therapeutic Apheresis Services
Request for Extracorporeal Photopheresis (ECP) - CTCL
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Patient Demographics
Surname
First Name(s)
NHS Number
D.O.B
Hospital Number
Patient Address
Patient Contact Number
Hospital
Ward / out Patient
Consultant Name
Consultant Contact Number
Height
Weight
GP Name
GP Address (inc. postcode)
Diagnostic criteria (tick all that apply)
CTCL Stage III
CTCL Stage IVA
Circulating T cell clone
Erythroderma
Histology consistent with CTCL
Sezary cells >10% circulating lymphocytes
CD4 / CD8 ratio > 10
Other Information
Is this an urgent referral?
Yes
No
Does the patient have any significant co-morbidities which would require modification of the procedure (e.g.
cardiovascular, renal, bleeding diathesis?
Medication:
Does the patient have any allergies?
Yes
No
(If yes, please specify)
A full blood count is included in the treatment package price. Please state any additional blood tests required and provide
the completed relevant request forms
ECP Exclusion Criteria
1. Pregnancy
Yes
No
2. History of heparin induced thrombocytopenia
Yes
No
3. Uncontrolled infection
Yes
No
4. Photosensitivity
Yes
No
5. Sensitivity to psoralen compounds
Yes
No
6. Aphakia
Yes
No
Yes
No
8. Platelet count < 20 x 109 / 1
Yes
No
9. Severe diarrhoea > 1000ml daily
Yes
No
7. Neutrophil count < 1 x
109
/1
(Template Version 01/11/13)
Cross-Referenced in Primary Document: MPD583
Page 1 of 2
FORM FRM4906/1.1
Effective: 17/02/15
Therapeutic Apheresis Services
Request for Extracorporeal Photopheresis (ECP) - CTCL
-
-
-
Vascular Access
(ECP requires 16g access in antecubital fossa and second access in opposite limb of at least 20g)
Are peripheral veins adequate for apheresis?
Yes
No
Is an apheresis central line already in place?
Yes
No
Will an apheresis central line be inserted?
Yes
No
(If yes, please advise date of insertion)
Detail of member of staff completing this form
Name:
Grade:
Phone Number:
Date:
Email address:
Signature:
(*To ensure confidentiality please ensure an nhs.net email address is provided)
For Use by NHS Blood & Transplant ONLY
Has the referral been accepted?
Yes
No
Comments:
(Template Version 01/11/13)
Cross-Referenced in Primary Document: MPD583
Page 2 of 2