Trust/gp address Date ifr team South, Central & West csu omega House 112 Southampton Road

Trust/GP address

Date

IFR team

South, Central & West CSU

Omega House

112 Southampton Road

Eastleigh SO50 5PB

[e-mail]

Dear team
Prior Approval– Hallux valgus (bunions)

Patient Name/ DoB
NHS Number
Referring GP/ practice
Consultant/ Providing Trust
Date of clinic

Surgery for hallux valgus (bunions) should only be offered when all the following conditions have been met.

The patient has been previously managed by MSK or podiatry services and that all footwear options have been exhausted.	☐
Date of previous assessment: Brief summary of previous interventions:

AND

Has significant functional impairment related to the hallux valgus.	☐
Please provide details of impairment:

AND

That the patient is fully informed and is aware of the pros and cons of surgery ☐

Please note it is the clinician’s responsibility to obtain patient consent to share this and all supporting materials with the Commissioning Support Unit. All information will be used and stored in accordance with the Data Protection Act.
Yours sincerely


Referring/Treating clinician GMC Number