To Doctor...... at...... Practice Date......
From Nurse...... at...... Nursing Home Tel......
Patient’s name ……………………….. Date of Birth …………… Wound type……………………….
Formulary Dressing / Dressing Type / Formulary size range inCentimetres(cm)
(Highlight required size) / Quantity requested / Frequency of change
Kerra Foam Gentle Border / Foam with soft silicone contact layer / 7.5x7.5cm, 10x10cm, 10 x20cm, 12.5x12.5cm
Sacrum:- 17x17.5cm & 23x26cm
Heel:- 25x23cm
Allevyn Gentle / Foam / 7.5 x7.5cm, 10 x10cm, 12.5 x12.5xm,
17.5 x17.5cm, 23 x23cm heel,
16.8 x 17.1cm sacrum
Allevyn Gentle Border light / Foam / 5 x5cm
Aquacel Foam adhesive / Foam / 5 x 5cm, 10 x10cm, 8 x 8 cm, 12.5 x12.5cm, 17.5x17.5cm, 21x21cm, 25 x30cm, 20x16.9cm (Sacral)
24 x21.5cm (Sacral),19.8x14cm (Heel)
Aquacel Foam non adhesive / Foam / 5 x5cm, 10 x10cm, 15 x15cm, 15 x20cm, 20 x20cm
Aquacel + Extra / Hydrofiber® / 5 x 5cm, 10x10cm & 15x15cm
Aquacel Ribbon / Hydrofiber® / 1x45cm & 2x45cm
Actilite / Honey (antimicrobial) / 5 x5cm, 10x10cm & 10 x20cm
Algivon plus / Honey (antimicrobial) / 5x5cm, 10x10cm & 2.5 x20cm
Atrauman Ag / Silver (antimicrobial) / 5x5cm, 10x10cm & 10x20cm
Aquacel Ag + extra / Silver (antimicrobial) / 5x5cm, 10x10cm & 15x15cm
Aquacel Ag + ribbon / Silver (antimicrobial) / 1x45cm & 2x45cm
Atrauman (Store Flat) / Low/Non-Adherent / 5x5cm, 7.5x10cm & 10x20cm
Aquaform 15g / Hydrogel / 15 gram
Carboflex / Carbon (odour management) / 10x10cm, 8 x15cm oval &15x20cm
CliniSorb / Carbon (odour management) / 10x10cm, 10x20cm & 15x25cm
MediDerma-S
No Sting Barrier Film/ cream / Skin Protectant / Barrier cream (2g sachets or tubes)
1ml barrier film applicator (pack of five)
50ml aerosol spray Barrier film
Comfeel Plus transparent / Hydrocolloid film dressing (light exudate only) / 5 x7cm
Comfeel Plus Ulcer / Hydrocolloid film dressing (low to moderate exudate) / 10 x10cm
Comfeel Plus Contour / Conformable Hydrocolloid film dressing (low to moderate exudate) / 6 x8cm & 9 x11cm
Cosmopor E / Post-Op / 8x10cm, 10x25cm & 5 x 7.2cm
OpSite Post-Op / Post-Op / 8.5 x 9.5cm, 8.5 x15.5cm, 10x25cm,
12x10 cm & 10 x35cm
Clearfilm / Vapour permeable film / 6x7cm, 10x12cm, 12x12cm & 15x20cm
DuoDERM Extra Thin / Hydrocolloid / 7.5.x.7.5cm,10x10cm & 15 x 5cm
DuoDERM Signal / Hydrocolloid / 10x10cm, 14x14cm
18.5x19.5cm heel & 11x19cm oval
Xupad / Absorbent / 10 x12cm,10x10cm,20x20cm & 20x40cm
Kerra Max Care / Super Absorbent protease modulating / 10x22cm, 20x30cm,(20x50cm size with TVS Nurse Advice only)
Sorbsan flat &
Sorbsan packing / Alginate / 5x5cm &,10x10cm flat
2g packing with probe
V.4.1 Written by: LC Sahlman Checked By: I Gratrix Medicines Management Team January 2017
This facsimile transmission is STRICTLY CONFIDENTIAL and intended only for the person or organisation to which it is addressed. It may contain privileged and confidential information. If you have received this facsimile in error, please notify the sender as soon as possible.
V.4.1 Written by: LC Sahlman Checked By: I Gratrix Medicines Management Team January 2017