† Lines are open 8am to 6pm Monday to Friday, and 8am to 4pm Saturday. We may record or monitor our calls. To pre-authorise funding for Bupa patients, we’d be grateful if you could: Complete every section of this form so we can assess whether treatment is eligible for funding under our customers’ health insurance schemes. We’ll let you know within three working days of receiving your completed form. If we need to ask for more information, it’s likely to delay our funding decision and the patient’s treatment. Please tick here if you need an urgent response Type on the form, rather than handwriting it, and return it by secure email: [email protected] or fax: 01784 234 295. Please be aware that information you send to this email address may not be secure unless you send us your email through Egress Switch. For more information and to sign up for a free Egress Switch account, go to https://switch.egress.com/ui/learn . You won’t be charged for sending secure emails to a Bupa email address using the Switch service. If you’ve any questions, please call us on: 0161 873 9024*. Patient and consultant information: Patient’s name: Consultant’s name: Date of birth: Bupa Provider Number: Bupa Membership Number: Phone number: History of the patient’s lesion: Where is the lesion situated? Please tick history: crust newly appeared change in shape itch / soreness change in size change in colour bleeding Risk factors: Previous medical history of skin cancer(s) removed: Family history of cancer? Skin type? Number of blistering sunburns? Please tick sun exposure history: occupation sunbathe/sunbeds outdoor hobbies residence/travel abroad Personal medical history: Pacemaker? Yes No Defibrillator? Yes No Drug history: Anticoagulants? Yes No Immunosuppressants? Yes No Does the patient have any allergies? Yes No Pre-authorisation: Minor skin lesion procedures