Dressing Order Form - requests from community nurses for prescriptions
Patient Name & Address:
Ordered by:
Patients GP Name and GP address:
Wound type:
Designation:
Allergies:
NHS No:
Patient D.O.B:
Name
Size
Nurse Contact
Telephone No:
QTY
Name
st
Date of request:
Size
Treatment Length (Max 2 weeks):
QTY
Name
Size
DUODERM SIGNAL
DURAFIBER RIBBON
11 x 19cm
2 x45cm
5cm x 5cm
10cm x 10cm
15cm x 15cm
5cm x5m
10cm x5m
2.5cm x10m
5cm x10m
10cm x10m
15cmx10m
20cm x10m
30cm x10m
7.5cm x6m
5cm x 5cm
9.5cm x 9.5cm
10cm x10cm
10cm x20cm
10cm x40cm
5g
10g
20ml pod
5cm x 4mtr
7cm x 4mtr
1 line products (Max 2 weeks supply)
ACTICO bandage
ACTILITE
ADVADRAW
ADVADRAW SPIRAL
ALLEVYN non adhesive
AQUAFORM Hydrogel
ATRAUMAN
ATRAUMAN AG
CLINIPORE
CLINISORB
COMFIFAST (Green)
4cmx6m
6cmx6m
8cmx6m
10cmx6m
12cmx6m
10x10cm
10x20cm
5 x 7.5cm
0.5cm x 40cm
5cmx5cm
10cmx10cm
10cm x 20cm
20cm x 20cm
COMFIFAST (Red)
COMFIFAST (Blue)
COMFIFAST (Beige)
COMFIFAST (Yellow)
COSMOPOR E
8g
5x5 cm
7.5x10 cm
10x20 cm
20x30 cm
5x5 cm
10x10 cm
10x20 cm
1.25cm
C-VIEW
C-VIEW POST OP
2.5cm
10 x 10 cm
5x1m
5x3m
5x5m
3.5x1m
7.5x1m
7.5x3m
7.5x7.5m
17.5x1m
10.75x1m
10.75x3m
10.75x5m
10cm x 20cm
10cm x 25cm
10cm x 35cm
5cm x 7.2cm
6cm x 10cm
6cm x 15cm
8cm x 10cm
8cm x 15cm
8cm x 20cm
6x7cm
10 x 12cm
12 x 12cm
15 x 20cm
6 x 7cm
10 x 12cm
10 x 25cm
10 x 35cm
DUODERM EXTRA THIN
DUODERM SIGNAL
7.5 x 7.5cm
10 x10cm
15 x 15cm
10 x 10cm
DURAFIBER
HYPAFIX
ICTHOPASTE BANDAGE
INADINE
INTRASITE Conformable
IODOFLEX
IRRIPOD
K-BAND Retention
bandage
KERRAPED
10cm x 4mtr
15cm x 4mtr
Small
Medium
Large
QTY
Dressing Order Form - requests from community nurses for prescriptions
1st line products continued
LIMBO waterproof protectors
MEDIHONEY Antibac wound gel
MEDIHONEY Apinate
MEDIHONEY Apinate Ribbon
MEDIHONEY Barrier cream
MEDIHONEY WOUND GEL
NA ULTRA
SORBADERM barrier FILM
SORBADERM CREAM
SORBSAN
SORBSAN PLUS
SORBSAN PLUS BORDER
Ancillary Products
S
M
L
EXL
20G
50G
5x5cm
10x10cm
1.9 x 30cm
50g
2g sachets
SORBSAN Packing
SORBSAN Ribbon
SORBSAN SILVER Flat
SORBSAN SILVER Packing
SORBSAN SILVER Ribbon
STERILE Dressing pack (Sp10)
2g
40cm
5x5cm
10x10cm
2g
1g
1 pack
2.5cm
5cm
8x8cm
11x11cm
15x15cm
TRANSPORE
XTRASORB HCS
10g
10x10cm
ZETUVIT E
20g
9.5x9.5cm
10x20cm
20x20cm
2nd line products (Max 2 weeks supply)
19x9.5cm
1mlx5
3ml x 5
28ml
2g
92g
5x5 cm
10x10cm
10x20cm
10x15cm
10x20 cm
11.5cm x 14cm
14cm x 19cm
14cm x 24cm
19cm x 24cm
ACTIFORM COOL
ALLEVYN GENTLE Border
ALLEVYN GENTLE Border heel
ALLEVYN gentle border Multisite
AQUACEL AG EXTRA
AQUACEL AG Ribbon
5x6.5cm
10x10cm
10x15cm
7.5cmx7.5cm
10cmx10cm
12.5x12.5cm
17.5x17.5cm
23 x 23.2cm
17.1x17.9cm
5x5
10x10 cm
15x15 cm
1x45cm
2x 45cm
CARBOFLEX ODOUR
KERRAMAX CARE
KIND Removal tape
URGOTUL
8x15 cm
10x10 cm
10cm x10cm
22cm x10cm
22cm x20cm
30cm x20cm
2.5cm x 5m
5cm x 5m
5x5 cm
10x10
15x20
20x30
3rd line products (Max 2 weeks supply)
ACTICOAT FLEX
ACTICOAT FLEX
AQUA
ANABACT
DEBRISOFT
ECLYPSE BOOT
FLAMINAL FORTE,
FLAMINAL HYDRO
HAELAN Cream
HAELAN TAPE
KERRAPED Plantar ulcer
MEPIFORM
MEPITEL
POLYMEM Finger /toe
SORBION SACHET extra
SUPRASORB X + PHMB
To be prescribed directly
via TV nurse, wound
care clinic nurses,
vascular nurse,
GP/consultant,
podiatrist or on their
behalf following
professional
recommendation.
For any non-formulary requests, please discuss this with the Tissue Viability Nurse
Size
Quantity
PRESCRIPTION DETAILS:
Collected by Patient/Relative/ Nurse ⃝ Name:
Deliver to nominated Pharmacy ⃝
Name:
This fax is confidential and is intended only for the person to whom it is addressed. If you have received this fax in error, please notify us immediately by telephone on the number shown on the first
page and return the message to us by post. If the reader of this fax is not the intended recipient, you are hereby notified that any distribution or copying of the message is strictly prohibited.