Woundcare Prescription Request Form
Please complete to request prescriptions for wound care products from G.P. Practices
Consult formulary for any restrictions. Please order no more than TWO weeks supply
Patient’s Name:NHS Number:
Address: / Ordered By: Base/Location:
GP practice:
Sign: Date…../…./ 20…..
Dressing change Frequency
(Please tick to indicate) / Daily / Twice weekly / Weekly / Other(please specify) / Number of sites dressed
Dressing / Size / Quantity / Dressing / Size / Quantity
Acti-fast 2-way stretch
stockinette / 7.5cm Width / Flivasorb
(remember to step down when exudate decreases) / 10cm x 10cm
1 Metre(Blue Line) / 10cm x 20cm
3 Metre(Blue Line) / 20cm x 20cm
5Metre(Blue Line) / 20cm x 30cm
10.75cm Width / Hydrofilm / 6cm x 7cm
1 Metre (Yellow Line) / 10cm x12.5cm
3 Metre (Yellow Line) / 10cm x 15cm
5 Metre (Yellow Line) / 15cm x 20cm
17.5cm Width / 12cm x 25cm
1 Metre (Beige Line) / 20cm x 30cm
Actiform Cool Sheet / 5cm x 6.5cm / Mepilex / 5cm x 5cm
10cm x10cm
10cm x15cm
Aquacel Foam Adhesive / 8cm x 8cm / Mepilex XT / 10cm x 11cm
10cm x 10cm
12.5cm x 12.5cm / 15cm x16cm
17.5cm x17.5cm
19.8cm x14cm (Heel) / Mepilex Border Heel / 18.5cm x 24cm
20cm x16.9cm (sacral)
24cm x 12.5cm (sacral) / Mepilex Border Sacrum / 15cm x 15cm
Aquacel Extra Dressing / 5cm x 5cm / 18cm x 18cm
10cm x10cm / 23cm x 23cm
15cm x 15cm
Aquacel Ribbon / 1cm x 45cm / Mepilex Border / 7.5cm x 7.5cm
2cm x45cm / 10cm x 12.5cm
Clinisorb ( Activated charcoal dressing for odour control) / 10cm x 20cm
15cm x 17.5cm
Cosmopor E / 5cm x7.2cm / Mepitel One / 6cm x 7cm
9cm x10cm
5cm x 10cm / 13cm x15cm
8cm x10cm / 24cm x32cm
8cm x 15cm / Mextra Superabsorbent / 10cm x 10cm
10cm x20cm / 10cm x 15cm
10cm x 25cm / 10cm x 20cm
10cm x 35cm / 15cm x20cm
Duoderm extra thin / 7.5cm x7.5cm / 20cm x25cm
10cm x 10cm / 20cm 30cm
Exufiber / 5cm x 5cm / NA Ultra / 9.5cm x9.5cm
4.5cm x 10cm / 19cm x9.5cm
10cm x 10cm / Viscopaste BP7 10% Zinc Paste bandage / 7.5cm x 6 Metre
15cm x 15cm
20cm x 30cm / Zetuvit E Sterile / 10cm x 10cm
10cm x 20cm
2cm x 50cm / 20cm x 20cm
20cm x 40cm
Emollients
Product / Size / Quantity / Product / Size / Quantity
Dermol 600 / 600ml / Zeroderm ointment / 125g
500g (as soap substitute)
Dermol 200 shower / 200ml / Zerodouble gel / 100g
475g
Dermol 500 cream / 500g / Liquid paraffin and white soft paraffin 50/50 / 500g
Zerobase emollient cream / 50g / You do not need to wait for authorisation before issuing dressings on exemption Forms
500g
Woundcare Prescription Request Form
Please complete to request prescriptions for wound care products from G.P. Practices
Consult formulary for any restrictions. Please order no more than TWO weeks supply
Patient’s Name:NHS Number:
Address: / Ordered By: Base/Location:
GP practice:
Sign: Date…../…./ 20…..
Dressing change Frequency
(Please tick to indicate) / Daily / Twice weekly / Weekly / Other(Please specify) / Number of Sites Dressed
Compression Hosiery
Activa Acti-Lymph
Activa Leg Ulcer Kit (can be used as an alternative for compression bandaging in appropriate patients)
Dressing / Size / Quantity / Dressing / Size / Quantity
Actico 2c Bandage 10cm
Width / 18cm-25cm / UrgoK-Two compression system
Seek specialist advice if using latex free product / 18cm-25cm / Size 0 short
Reduced compression
25cm-32cm / 8cm
10cm
Actico Short Stretch Compression Bandage / 8cm x 6m / 12cm
10cm x 6m / Latex free 10cm
12cm x 6m / Latex free 10cm reduced
FlexiBan (sub-compression wadding bandage Alternative to K-soft / 10cm x 3.5m / UrgoK-Two compression system
Seek specialist advice if using latex free product / 25cm-32cm / Reduced compression
8cm
10cm
12cm
Latex free 10cm
K-Lite bandage / 5cm x 4.5m
7cm x 4.5m
10cm x 4.5m
Miscellaneous Products and sundries
Product / Size / Quantity / Product / Size / Quantity
Non-woven fabric swabs Non-Sterile / 10cm x 10cm / Irripod / 20ml ampoule
Sorbaderm- Remember applications TWICE weekly for foam applicators / 1ml Foam Applicator / Clinipore tape / 1.25cm x 5m
28g barrier cream / 2.5cm x 5m
2g sachets (request single sachets) / 5cm x 5m
Cavilon- Remember applications TWICE weekly for foam applicators / 28g Durable barrier cream / Dressit Packs (only for sterile/invasive procedures)
Request as single packs / Small/medium
1ml foam applicator / Medium/Large
2g sachets(request single sachets)
Granugel / 15g
Specialist Dressings/Preparations: In 2014/15 we spent more than £300,000 on silver dressings, A growth of 23% compared to 2013/14. Silver dressings have a limited place in therapy. All anti-microbials are for short term use, you should seek clinician advice if needed for longer.
Product / Size / Quantity / Product / Size / Quantity
Activon medical grade Manuka honey dressing / 25g tube / Iodoflex Paste / 5g
10g
Activon Tulle Gauze / 5cm x 5cm / Povitulle (equivalent to Inadine) / 5cm x 5cm
10cm x 10cm / 10cm x 10cm
Aquacel Ag + Extra / 5cm x 5cm / Melgisorb Ag / 5cm x 5cm
10cm x 10cm / 10cm x 10cm
15cm x 15cm / 15cm x 15cm
Aquacel Ag + Ribbon / 1cm x 45cm / Mepilex Ag / 10cm x 10cm
2cm x 45cm
Debrisoft Debridement Pad (Maximum ONCE weekly use, only if debridement required) / 10cm x 10cm / 10cm x 20cm
15cm x 15cm
20cm x 20cm
Flaminal Hydro / 15g / Urgotul SSD / 10cm x 12cm
Flaminal Forte / 15g / 15cm x 20cm
Avance Negative pressure kits and accessories. Please clearly indicate product required
Remember to complete an exemption form if a non-formulary product is required,
You do not need to wait for authorisation. / Please Tick
Tick to confirm exemption form has been completed and faxed to the TVN team on 01952 607785
Tick to confirm exemption form has been completed and faxed or sent via Emis to the relevant G.P Practice