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FORM 1 Prescription Request for First Choice Dressings 2019 v13Requested by: <<Name of Nurse>> on <<Date>>For queries, please contact: Patient Name:?Patient_Title? ?Patient_First_Forename? ?Patient_Surname?NHS Number:?Patient_NHS_Number? Date of Birth:?Patient_Date_Of_Birth?Patient Address:Patient Telephone Number:Community Pharmacy:Patient wishes theprescription to be:Left at Surgery for collection by patient or representative (delete as applicable)Forwarded to Pharmacy for collection by patient or representative (delete as applicable)Forwarded to Pharmacy for delivery to patient (delete as applicable)Notes:Shaped dressings are not on the First Choice Dressings List and require completion of Form 2 for non-formulary request (see below).DescriptionNumber of dressings used at each dressing changeNumber of times the dressing is changed each weekNumber of weeks supply required (Max 4 weeks)Type of wound e.g. pressure ulcer, leg ulcer, traumatic wound, burn, surgical woundRationale e.g. new treatment / change of treatment / multiple woundsAlginate/Gelling FibreKerraCel dressing 5cm x 5cm square (Crawford Healthcare Ltd)KerraCel dressing 10cm x 10cm square (Crawford Healthcare Ltd)KerraCel dressing 15cm x 15cm square (Crawford Healthcare Ltd)KerraCel dressing 2.5cm x 45cm ribbon (Crawford Healthcare Ltd)Urgosorb Pad dressing 10cm x 10cm (Urgo Ltd)Urgosorb Pad dressing 5cm x 5cm (Urgo Ltd)Urgosorb Rope dressing 30cm (Urgob Ltd)Cleansing SolutionsStericlens sodium chloride 0.9% irrigation solution aerosol spray (C D Medical Ltd) 240mlOctenilin irrigation solution 350ml bottles (Schulke & Mayr UK Ltd) 350mlContact LayerAtrauman dressing 5cm x 5cm (Paul Hartmann Ltd)Atrauman dressing 7.5cm x 10cm (Paul Hartmann Ltd)Atrauman dressing 10cm x 20cm (Paul Hartmann Ltd)Atrauman dressing 20cm x 30cm (Paul Hartmann Ltd)Mepitel One dressing 6cm x 7cm (Molnlycke Health Care Ltd)Mepitel One dressing 9cm x 10cm (Molnlycke Health Care Ltd)Mepitel One dressing 13cm x 15cm (Molnlycke Health Care Ltd)FilmClearFilm I.V. dressing 7cm x 9cm (Richardson Healthcare Ltd)ClearFilm I.V. dressing 10cm x 15cm (Richardson Healthcare Ltd)FoamsTegaderm Foam dressing (adhesive) 6.9cm x 7.6cm oval (3M Health Care Ltd)Tegaderm Foam dressing (adhesive) 10cm x 11cm oval (3M Health Care Ltd)Tegaderm Foam dressing (adhesive) 14.3cm x 14.3cm square (3M Health Care Ltd)Tegaderm Foam dressing (adhesive) 14.3cm x 15.6cm oval (3M Health Care Ltd)Tegaderm Foam dressing (adhesive) 19cm x 22.2cm oval (3M Health Care Ltd)Foams with SiliconeBiatain Silicone dressing 7.5cm x 7.5cm (Coloplast Ltd)Biatain Silicone dressing 10cm x 10cm (Coloplast Ltd)Biatain Silicone dressing 10cm x 20cm (Coloplast Ltd)Biatain Silicone dressing 10cm x 30cm (Coloplast Ltd)Biatain Silicone dressing 12.5cm x 12.5cm (Coloplast Ltd)Biatain Silicone dressing 15cm x 15cm (Coloplast Ltd)Biatain Silicone dressing 17.5cm x 17.5cm (Coloplast Ltd)Mepilex Border Comfort dressing 7.5cm x 7.5cm (Molnlycke Health Care Ltd)Mepilex Border Comfort dressing 10cm x 10cm (Molnlycke Health Care Ltd)Mepilex Border Comfort dressing 12.5cm x 12.5cm (Molnlycke Health Care Ltd)Mepilex Border Comfort dressing 15cm x 15cmMepilex Border Comfort dressing 15cm x 20cm (Molnlycke Health Care Ltd)Hydrocolloid - ThinDuoDERM Extra Thin dressing 7.5cm x 7.5cm square (ConvaTec Ltd)DuoDERM Extra Thin dressing 10cm x 10cm square (ConvaTec Ltd)DuoDERM Extra Thin dressing 15cm x 15cm square (ConvaTec Ltd)DuoDERM Extra Thin dressing 9cm x 25cm rectangular (ConvaTec Ltd)DuoDERM Extra Thin dressing 9cm x 35cm rectangular (ConvaTec Ltd)AbsorbentsZetuvit E non-sterile dressing 10cm x 10cm (Paul Hartmann Ltd)Zetuvit E non-sterile dressing 10cm x 20cm (Paul Hartmann Ltd)Zetuvit E non-sterile dressing 20cm x 20cm (Paul Hartmann Ltd)Zetuvit E non-sterile dressing 20cm x 40cm (Paul Hartmann Ltd)Super AbsorbentsZetuvit Plus dressing 10cm x 10cm (Paul Hartmann Ltd)Zetuvit Plus dressing 10cm x 20cm (Paul Hartmann Ltd)Zetuvit Plus dressing 20cm x 25cm (Paul Hartmann Ltd)Zetuvit Plus dressing 20cm x 40cm (Paul Hartmann Ltd)KerraMaxCare dressing 10cm x 10cm square (Crawford Healthcare Ltd)KerraMaxCare dressing 10cm x 22cm rectangular (Crawford Healthcare Ltd)KerraMaxCare dressing 20cm x 22cm rectangular (Crawford Healthcare Ltd)KerraMaxCare dressing 20cm x 22cm rectangular (Crawford Healthcare Ltd)KerraMaxCare dressing 20cm x 30cm rectangular (Crawford Healthcare Ltd)KerraMaxCare dressing 20cm x 50cm rectangular (Crawford Healthcare Ltd)Antimicrobial IodineIodoflex paste 5g sachets (Smith & Nephew Healthcare Ltd)Iodoflex paste 10g sachets (Smith & Nephew Healthcare Ltd)Iodoflex paste 17g sachets (Smith & Nephew Healthcare Ltd)Inadine dressing 5cm x 5cm (Systagenix Wound Management Ltd)Inadine dressing 9.5cm x9. 5cm (Systagenix Wound Management Ltd)Antimicrobial HoneyMedihoney Antibacterial Honey Apinate dressing 5cm x 5cm square (Derma Sciences Europe, Ltd)Medihoney Antibacterial Honey Apinate dressing 10cm x 10cm square (Derma Sciences Europe, Ltd)Medihoney Antibacterial Medical Honey dressing (Derma Sciences Europe, Ltd) 20gAntimicrobial SilverAquacel Ag+ Extra dressing 5cm x 5cm square (ConvaTec Ltd)Aquacel Ag+ Extra dressing 10cm x 10cm square (ConvaTec Ltd)Aquacel Ag+ Extra dressing 15cm x 15cm square (ConvaTec Ltd)Aquacel Ag+ Extra dressing 20cm x 30cm rectangular (ConvaTec Ltd)Aquacel Ag+ Ribbon dressing 1cm x 45cm (ConvaTec Ltd)Aquacel Ag+ Ribbon dressing 2cm x 45cm (ConvaTec Ltd)Antimicrobial OtherZorflex dressing 5cm x 5cm square (H & R Healthcare Ltd)Zorflex dressing 10cm x 10cm square (H & R Healthcare Ltd)Zorflex dressing 10cm x 20cm rectangular (H & R Healthcare Ltd)Zorflex dressing 15cm x 25cm rectangular (H & R Healthcare Ltd)Cutimed Sorbact swab 4cm x 6cm (BSN medical Ltd)Cutimed Sorbact swab 7cm x 9cm (BSN medical Ltd)Cutimed Sorbact Ribbon dressing 2cm x 50cm (BSN medical Ltd)Cutimed Sorbact Ribbon dressing 5cm x 200cm (BSN medical Ltd)Low/Non AdherentMepore dressing 7cm x 8cm (Molnlycke Health Care Ltd)Mepore dressing 10cm x 11cm (Molnlycke Health Care Ltd)Mepore dressing 11cm x 15cm (Molnlycke Health Care Ltd)Mepore dressing 9cm x 20cm (Molnlycke Health Care Ltd)365 Transparent Island dressing 12x10cm365 Transparent Island dressing 20mx10cmMedicated BandagesViscopaste PB7 bandage 7.5cm (Smith & Nephew Healthcare Ltd)Ichthopaste bandage 7.5cm (Smith & Nephew Healthcare Ltd)Retention Bandages Knit-Band bandage 5cm x 4m (CliniSupplies Ltd)Knit-Band bandage 7cm x 4m (CliniSupplies Ltd)Knit-Band bandage 10cm x 4m (CliniSupplies Ltd)Knit-Band bandage 15cm x 4m (CliniSupplies Ltd)BandagesK-Soft Long bandage 10cm x 4.5m (Urgo Ltd)K-Lite bandage 10cm x 4.5m (Urgo Ltd)Bandages - CompressionActico bandage 10cm x 6m (L&R Medical UK Ltd)Actico bandage 10cm x 6m (L&R Medical UK Ltd)K-Plus 10cm x 8.7m M/Layer Compress BandagingUrgoKTwo multi-layer compression bandage kit (10cm) 18cm-25cm ankle circumference (Urgo Ltd)UrgoKTwo multi-layer compression bandage kit (10cm) 25cm-32cm ankle circumference (Urgo Ltd)UrgoKTwo Reduced multi-layer compression bandage kit 18cm-25cm ankle circumference (Urgo Ltd)UrgoKTwo Reduced multi-layer compression bandage kit 25cm-32cm ankle circumference (Urgo Ltd)Adhesive TapeClinipore tape 2.5cm (CliniSupplies Ltd)Clinipore tape 5cm (CliniSupplies Ltd)Hypafix tape 5cm (BSN medical Ltd)Hypafix tape 10cm (BSN medical Ltd)Tubular Bandages CliniFast stockinette 7.5cm (CliniSupplies Ltd) BlueCliniFast stockinette 10.75cm (CliniSupplies Ltd) YellowCliniFast stockinette 17.5cm (CliniSupplies Ltd) BeigeEmollientsQV Gentle wash (Crawford Healthcare Ltd) 250mlQV cream (Crawford Healthcare Ltd) 500gZeroderm ointment (Thornton & Ross Ltd) 500gZerobase 11% cream (Thornton & Ross Ltd) 500gZerodouble gel (Thornton & Ross Ltd) 500gZeroveen cream (Thornton & Ross Ltd) 500gWhite soft paraffin 50% / Liquid paraffin 50% ointmentBarrier creams/skin protectors- These must be ordered on the ‘Barrier products request form’ providing rationale for use which is available on the following link queries, please contact:This form should only be used when there is a valid rationale, which should be clearly stated.Description (include full name of product and size)Number of dressings used at each dressing changeNumber of times the dressing is changed each weekNumber of weeks supply required (Max 4 weeks)Type of wound e.g. pressure ulcer, leg ulcer, traumatic wound, burn, surgical woundRationale e.g. new treatment / change of treatment / multiple woundsRationale for use of off list dressing:Please use this box to give rationale for prescribing outside of the formulary and attach a copy of the patient’s current wound care chart.What is the problem? Is this a new treatment or change of treatment? If a change please state what is being stopped. What is the likely duration of treatment (more or less than 4 weeks)? ................
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