East Lancashire Medicines Management Board representing East Lancashire Hospital NHS Trust, BwD CCG and East Lancs CCG
DRESSING PRESCRIPTION REQUEST FORM
To be completed to request prescriptions of wound care products from GPs in line with East Lancashire Joint Wound Care Formulary (www.elmmb.nhs.uk)
Consult formulary for any restrictions. Please order no more than one month's supply.
Patient Name: ………………………………….. DOB: ……………… NHS no: ……………Address: ………………………………………………………………………………………………………………
GP name: ……………………………………….
Practice name: ………………………………………………………………………….… Date and time: ……………………….
Staff name: …………………………………………………………. Base: …………………………..
twice daily
Visit Frequency (please indicate)
daily
twice weekly
Service: …………………………………..…Phone no: ………………………..……
weekly
other
Comments: ……………………………………………………………………………………….
Quantity
in units
WARNING: Dressings with 'Ag' in the name are SILVER DRESSINGS and are not approved for prescribing in the East Lancashire Health Economy
Actico Bandage
ActiformCool sheet
Actilite Gauze
ActivHeal Alginate
Activheal Foam Adhesive
Activheal Non-Adhesive Foam
Activheal Hydrocolloid Dressing
ActivHeal Hydrogel
Activon Honey Gel Dressing
Adaptic Touch
Advazorb Border
Advazorb Border Lite
AdvaZorb Silfix
Algivon Dressing
Aquacel Foam Adhesive
Aquacel Foam Non-Adhesive
Askina Silicone Adhesive Border
Askina Non-Adhesive
LCFT ONLY
LCFT ONLY
LCFT ONLY
ELHT ONLY
ELHT ONLY
ELHT ONLY
ELHT ONLY
Atrauman Dressing
Biatain Alginate!! CORRECT PRODUCT
SELECTED ON PRESCRIBING SCREEN?
Biatain soft-hold
LCFT ONLY
Clinisorb
Coban 2 Bandaging Kit ELHT ONLY
Comfifast Stockinette Red Line
Comfifast Stockinette Green Line
Comfifast Stockinette Blue Line
Comfifast Stockinette Yellow Line
Comfifast Stockinette Beige Line
Comfifast EasyWrap Stockinette
Cutimed Sorbact Ribbon
Cutimed Sorbact Swab
Cutimed Sorbact Gel Dressing
Diaphane / Instinct Hosiery
Durafiber
Hydrofilm Dressing
8cm x 6m
5cm x 6.5cm
10cm x 10cm
5cm x 5cm
7.5cm x 7.5cm
10cm x6m
10cm x 10cm
10cm x 20cm
10cm x 10cm
10cm x 10cm
12cm x 6m
10cm x 15cm
20cm x 20cm
5cm x 5cm
10cm x 20cm
12.5cm x 12.5cm
2.5cm x 30cm ROPE
15cm x 15cm
5cm x 5cm
5cm x 7.5cm
8g
25g
5cm x 7.6cm
7.5cm x 7.5cm
7.5cm x 7.5cm
7.5cm x 7.5cm
5cm x 5cm
8cm x13cm
5cm x 5cm
7.5 x 7.5cm
5cm x 7cm
5cm x 5cm
5cm x 5cm
10cm x 10cm
10cm x 10cm
15g
10cm x 20cm
15cm x 15cm
20cm x 20cm
15cm x 18cm
7.6cm x 11cm
10 x 10cm
10cm x 10cm
10cm x 10cm
10cm x 10cm
10cm x 10cm
10cm x 10cm
10 x 10cm
10cm x 10cm
7.5cm x 10cm
10cm x 10cm
12.7cm x 15cm
12.5cm x 12.5cm
20cm x 32cm
15 x15cm 10 x 20cm 20cm x 20cm
12.5cm x 12.5cm
12.5cm x 12.5cm
15 x15cm 10x20cm
15cmx15cm
20cm x 20cm
10cm x20cm
10cm x 20cm
10cm x 20cm
15 x 15cm
10cm x 20cm
10cm x 20cm
15cm x 15cm
12.5cm x 12.5cm
15cm x 15cm
20 x 20cm
15cm x 15cm
20cm x 30cm
44cm ribbon
17.5cm x 17.5
cm
15cm x 20cm
5cm x 7cm
10cm x 10cm
1 size
3.5cm x 1m
10cm x 10cm
10cm x 20cm
15cm x 15cm
15cm x 25cm
10cm x 20cm
Note: highly exuding wounds only
20cm x 20cm
Foam Heel 12cm x 18cm
10cm x 30cm
10cm x 30cm
20cm x 20cm
21cm x 21cm
15cm x 20cm
25cn x 30cm
20cm x 20cm
20cm x 20cm
Note: highly exuding wounds only
5cm x 1m
5cm x 3m
5cm x 5m
7.5cm x 1m
7.5cm x 3m
7.5cm x 5m
10.75cm x 1m
10.75cm x 3m
10.75cm x 5m
17.5cm x 1m
Garments - state size and type (available in sizes for 6 months - 14 years)
2cm x 50cm
5cm x 200cm
4xm x 6cm
7cm x 9cm
Note: Burns only. Minor Injuries Only
7.5cm x 7.5cm
7.5cm x 15cm
5cm x 5cm
6cm x 7cm
10cm x 10cm
10cm x 12.5cm
15cm x 15cm
10cm x 15cm
4cm 10cm
12cm x 25cm
4cm x 20cm 4cm x 30cm
15cm x 20cm 20cm x 30cm
2 x 45cm
Hypafix Adhesive Tape
Inadine
Iodoflex Paste
Iodosorb Ointment Dressing
Irripod sodium chloride 0.9% irrigation solution
IV3000 Dressing
K-Band bandage
K-Lite bandage
K-Soft bandage
K-Plus bandage
Ko-Flex bandage
K-ThreeC bandage
LeuKomed T Plus
N-A Dressing
5cm x 5m
5cm x 5cm
5g
10g
25 x 20ml
10cm x 12cm
5cm x 4m
5cm x 4.5m
10cm x 3.5m
10cm x 8.7m
10cm x 6m
10cm x 3m
7.2cm x 5cm
9.5cm x 9.5cm
N-A Ultra Drssing
Ribbed Cotton Surgical Tubular Stockinette
Scanpor Tape
9.5cm x 9.5cm
19.5cm x 9.5cm
5cm x 5m
7.5cm 5m
10cm x 5m
1.25cm x 5m
2.5cm x 5m
5cm x 5m
1.25cm x 10m
2.5cm x 10m
5cm x 10m
Ready made
Made to measure lower limb hosiery when standard not appropriate
6cm x7cm
10cm x 10cm
10cm x 15cm
28ml film spray
1ml foam applicator
3ml foam applicator
10cm x 20cm
10cm x 30cm
2g barrier cream (20 sachets per box)
6mm x 75mm x 3
10cm x 10cm
7.5cm x 6m
10cm x 10cm
10cm x 10cm
20cm x 40cm
20cm x 25cm
Sigvaris Cotton hosiery (ready made)
Sigvaris Cotton hosiery
Softpore
Sorbaderm
Steri-strip skin closure strips
Tegaderm hydrocolloid Dressing
Viscopaste PB7 Bandage
Zetuvit E Sterile Dressing
Zetuvit Plus Sterile Dressing
Acti-Glide Compression Hosiery Applicator
EZY-As Compression Hosiery Applicator
Sockaid Compression Hosiery Applicator
Small
10cm x 5m
9.5cm x 9.5cm
10g
20g
2.5cm x 10m
5cm x 10m
10cm x 10m
First 48 hours post-trauma only Minor Injuries Only
15cm x 10m
20cm x 10m
17g
Note: central lines only
7cm x 4m
10cm x 4m
7cm x 4.5m
10cm x 4.5m
15cm x 4m
15cm x 4.5m
10cm x 5.25m
10cm x 25cm
10cm x 30cm
10cm x 35cm
15cm x 5m
20cm x 5m
25cm x 5m
10cm x 4.5m (long)
10cm x 10.25m (long)
10cm x 7m (long)
8cm x 10cm
19cm x 9.5cm
10cm x 20cm
10cm x 12cm (oval)
13cm x 15cm (oval)
10cm x 20cm
10cm x 20cm
20cm x 20cm
15cm x 20cm
/ medium
/
7.5cm x 10m
28g barrier 92g barrier
20cm x 40cm
large
Podiatry only
Elastic Adhesive bandage BP 1993
Melolin
Sorbion Sachet Border (Diabetic foot use only)
Sorbion Sachet EXTRA (Diabetic foot use only)
Sorbion Drainage
5cm x 4.5m EHQ011
5cm x 5cm
10cm x 10cm
10cm x 10cm
15cm x 15cm
5cm x 5cm
7.5cm x 7.5cm
10cm x 10cm
7.5cm x 4.5m EHQ012
10cm x 20cm
25cm x 15cm
10cm x 10cm
20cm x 20cm
8g
25g
10cm x 4.5m EHG013
20cm x 10cm
30cm x 20cm
MacMillan Nurse use only
Intrasite Gel
15g
Please complete the table below if requesting a specialist product or a non-formulary item
Non-formulary/specialist dressing
Reason
for
requesting
formulary/specialist item
Has this form been faxed to the GP practice above?
Yes / No
nonSize
Quantity
Community Pharmacy contacted to arrange delivery? Yes / No
Name of specialist tissue
viability advisor consulted
Exception Form completed?
If Yes - which pharmacy? …………………………………………….
March 2015_v1