Continence Prescription Request Form 2015
This form aims to support GP Practices and promote improved governance, waste reduction and compliance
with Coastal West Sussex Continence Formulary.
To be completed when requesting any continence care products from a GP.
Patient Name
DOB
NHS number
Patient Address
Post Code
Practice Name
Practice Address
Pharmacy/DAC Name
Pharmacy/DAC
telephone no.
Pharmacy/DAC
fax
Prescription collection
details
Any supplies requested must comply with drug tariff specifications, paying particular attention to clause 12, which relates to out-of-pocket expenses.
The term “specialist” in this formulary refers to Bladder and Bowel Specialist Nurses, Urology Specialist Nurses and
Urologists. Items with this restricted coding should only be prescribed if recommended by these “specialists”.
Brand (Supplier)
Product Size
Code
Pack Size
Recommendation
DA3101
Prescribe in single
units
3 units initially, then 2 on
repeat
Prescribe in single
units
3 units initially, then 2 on
repeat
Prescribe in
single units
3 units initially, then 2
on repeat
Prescribe in single
units
3 units initially, then 2 on
repeat
Prescribe in single
units
3 units initially, then 2 on
repeat
Prescribe in
single units
3 units initially, then 2
on repeat
Prescribe in single
units
3 units initially, then 2 on
repeat
Prescribe in single
units
3 units initially, then 2 on
repeat
Prescribe in single
units
3 units initially, then 2 on
repeat
Prescribe in single
units
3 units initially, then 2 on
repeat
AA8C
Prescribe in
single units
3 units initially, then 2
on repeat
D2365
Prescribe in
single units
3 units initially, then 2
on repeat
<insert size>
D2369
Prescribe in
single units
3 units initially, then 2
on repeat
Instillagel 6ml (female)
40-006
1 x 10
Prescribe 5 as single units
Instillagel 11ml (male)
40-011
1 x 10
Prescribe 5 as single units
Cathejell with lidocaine 8.5g
CJL08501
1
Prescribe 5 as single units
Cathejell with lidocaine 12.5g
CJL12501
1
Prescribe 5 as single units
Quantity
Urinary catheters
Silicone – male
1st choice
Rusch Brilliant Aquaflate
12
14
16
<insert size>
2nd choice
Coloplast Folysil Silicone
12
14
AA8A
16
<insert size>
Specialist
use only
Rusch Brilliant
Silflate
12
14
16
DG3101
<insert size>
Silicone – female
1st choice
Rusch Brilliant Aquaflate
12
14
DA2101
16
<insert size>
2nd choice
Coloplast Folysil Silicone
12
14
AA8B
16
<insert size>
Specialist
use only
Rusch Brilliant
Silflate
12
14
16
DG2101
<insert size>
Hydrogel – male
1st choice
2nd choice
Rusch Sympacath
Aquaflate
Bard Aquamatic Biocath
12
14
DH3101
16
<insert size>
12
14
D2264
16
<insert size>
(pre-filled with sterile water)
Hydrogel – female
1st choice
2nd choice
Rusch Sympacath
Aquaflate
Bard Aquamatic Biocath
12
14
DH2101
16
<insert size>
12
14
D2268
16
<insert size>
(pre-filled with sterile water)
Open ended silicone
Coloplast Folysil
(standard length only)
12
14
16
18
<insert size>
Silver alloy coated
Bardex I.C. Foley Catheter
(standard length – male)
Bardex I.C. Foley Catheter
(standard length – female)
12 14 16 18 20 22
12
14
16
<insert size>
Lubricants
Lubricants with anaesthetic
1 of 4 | P a g e
Brand (Supplier)
Product Size
Code
Pack Size
Recommendation
CJM08501
1
Prescribe 5 as single units
CJM12501
1
Prescribe 5 as single units
Prescribe 1 pack per catheter
VESCP - 01
Prescribe in single
units
Prescribe in single
units
1
10540A
5
10 single units (every 8 weeks)
BFF5
5
10 single units (every 8 weeks)
Great Bear Fix It (leg strap)
Simpla G Strap (leg strap)
10644A
5
5 single units (every 4 months)
383001
5
5 single units (every 4 months)
Great Bear Fix It (abdominal strap)
10645B
5
5 single units (every 4 months)
Simpla G Strap (abdominal strap)
383003
5
5 single units (every 4 months)
9746609
10
10 units
9746625
10
10 units
FB99849
10
10 units
Small 24 – 39cm
15011
4
4 single units (every 4 months)
Medium 36 – 55cm
150121
4
4 single units (every 4 months)
Large 40 – 70cm
150131
4
4 single units (every 4 months)
Extra Large 65 – 95cm
150141
4
4 single units (every 4 months)
370802
10
10 bags (every 2 months)
370807
10
10 bags (every 2 months)
370817
10
10 bags (every 2 months)
376137
10
10 bags (every 2 months)
376138
10
10 bags (every 2 months)
376139
10
10 bags (every 2 months)
PSU2
10
3 packs per month
346145
10
10 bags (every 8 weeks)
Quantity
Lubricants without anaesthetic
Cathejell Mono 8.5g
Cathejell Mono 12.5g
Catheterisation packs
Cath-It 370 – 1034
Glove size S/M
908410
Cath-It 370 – 1042
Glove size M/L
908420
Prosys Vesica Clinic Pack
Prescribe 1 pack per catheter
Prescribe 1 pack per catheter
Urinary catheter valves
Libra Lever Catheter Valve
Bard Flip Flo Catheter Valve
Catheter tube restraining straps
Catheter maintenance solutions
Suby G Citric Acid 3.23% Twin 2x30mls
Solution R Citric Acid 6% Twin 2x30mls
Sodium Chloride 50mls (for mechanical flush only)
Leg bag holders
Bard Urisleeve leg bag holder
Urinary catheter leg bags
Slide action tap
Simpla Trident T1 Short Tube 350ml Leg Bag
Simpla Trident T1 Short Tube 500ml Leg Bag
Simpla Trident T1 Long Tube 500ml Leg Bag
Lever action tap
Simpla Trident 2 Short Tube 350ml Leg Bag
Simpla Trident 2 Short Tube 500ml Leg Bag
Simpla Trident 2 Long Tube 500ml Leg Bag
Urinary catheter bed bags/2 litre bags
Single Use 2 litre bags (unsterile)
ProSys Non Sterile Night Drainage bag 2L
Drainable 2 litre catheter bags (sterile)
Simpla S5 Night Bag
Belly bags
B1000
1
3 bags (every 12 weeks)
B1000P
1
3 bags (every 12 weeks)
B1000CT
1
3 bags (every 12 weeks)
Great Bear Catheter Leg Bag Straps
Sterile Water For Injection
10mls (plastic vials)
Conveen Prep
Appeel No Sting Medical Adhesive Remover wipes
Appeel No Sting Medical Adhesive Remover Spray
Hollister Retracted Penis Pouch
380812
10
10 single units
10
10 single units
62042
54 wipes
1x54
3505
30 wipes
1x30
3500
1
1 single unit
9811
10
1x10
Manfred Sauer p.hold 2cm (Penis Holder)
Manfred Sauer p.hold 4cm (Penis Holder)
PHN
1
1 single unit
PHW
1
1 single unit
A100-Plus
brief code
A110-Plus
brief code
A120-Plus
brief code
1
1 single unit
1
1 single unit
1
1 single unit
Rusch Belly Bag 1000ml (short outlet tube)
Rusch Belly Bag 1000ml (short outlet tube with sample port)
Rusch Belly Bag (with extra-long (60cm) outlet tube useful for wheelchair users)
Miscellaneous catheter supplies
Afex System
Afex Active Starter Pack
1 high receptacle, 1 pair of briefs, 1 reusable
collection bag, 1 cleaning container, 1 cleansing solution, 1 instructional DVD.
Afex Sedentary Starter Pack
1 low receptacle, 1 pair of briefs, 1 reusable
collection bag, 1 cleaning container, 1 cleansing solution, 1 instructional DVD.
Afex Mobility Assisted Starter Pack
1 supersoft receptacle, 1 pair
of briefs, 1 reusable collection bag, 1 cleaning container, 1 cleansing solution, 1 DVD.
2 of 4 | P a g e
Brand (Supplier)
Product Size
Code
Pack Size
Recommendation
Quantity
Afex Accessories
Briefs
Urine Collection
Bags
Receptacles
Extension tubes
and stabiliser
systems
A200-S-08
Waist S (28”-30”)
Waist M (32”-34”)
Waist L (36”-38”)
Waist XL (40”-42”),
Waist 2X (44”-46”),
Waist 3X (48”-50”)
500ml vented
500ml unvented
1200ml leg bag
Extra capacity
2000ml bed bag
Low receptacle
Low supersoft receptacle
High receptacle
Tube assembly complete
Tube stabiliser
Collection bag stabiliser-high grip
A200-M-08
A200-L-08
A200-XL-08
A200-2X-08
A200-3X-08
A400-V-08
A400-B-08
A400-L-08
A400-E-08
A400-X-08
A300-L-08
A300-S-08
A300-F-08
A700-A-08
A700-S-07
Prescribe in single
units
Prescribe in single
units
4 per year
9 per year
Prescribe in single
units
3 per year
Prescribe in single
units
Individual patient assessment
9 per year
A710-S-09
Individual patient assessment
Night bag holders
Not available on the NHS, but may be obtained from the following companies free of charge if their products are being used:
Simpla (Coloplast) bed bag stand
Telephone number = 0800 526177
ProSys (Clini Supplies) bed bag stand
Telephone number = 0800 0854957
Intermittent urinary catheters
Male
Teleflex Flocath Quick
Wellspect Healthcare Lofric
Optismooth
851241
30
904000-904800
25
OS4010-18
30
CL10-CL-14
30
Individual patient
assessment (6-8 per day)
Female
Clinimed Curan Lady
Braun Actereen Mini
Teleflex Liquick Base
228010E-228014E
30
630106-630114
60
225208E – 227216E
30
227308E – 227316E
30
Individual patient
assessment (6-8 per day)
With Bags
Actreen Glys Set male (with bag)
Actreen Glys Set female (with bag)
Holister Advance Plus (with bag)
Lofric Hydro-kit Male
Individual patient
assessment (6-8 per day)
92084 – 92184
25
4200825 - 4201825
20
851143
30
Individual patient
assessment (6-8 per day)
USMD08-18
25
Individual patient
assessment (6-8 per day)
Tiemann tip
Male Tiemann Tip
Male Dilator
Ultra Smooth Metal Dilator
Sheaths and leg bags
Manfred Sauer P-Sure (latex free, selfadhesive sheath, standard length only)
Rochester Freedom Transfix (100% clear
silicone sheath)
Conveen Optima (latex free self –
adhesive sheath)
Small:
20mm 22mm 24mm
Medium:
26mm 28mm 30mm
Large:
32mm 35mm 37mm 40mm
Style 1 Standard Length
(9cm):
25mm 29mm 32mm
36mm 41mm
Style 2 Shorter Length:
25mm 29mm 32mm
36mm 41mm
Style 3 Standard Length,
(extra wide adhesive)
25mm 29mm
32mm 36mm
41mm
Standard Length:
25mm 30mm 35mm
40mm
Shorter Length:
21mm 25mm 30mm
35mm
97.
30
<insert size>
97.
30
<insert size>
97.
30 single items
(once every 28 days)
30
<insert size>
TF1<insert size> 30
30 single items
(once every 28 days)
30 single items
(once every 28 days)
30
30 single items
(once every 28 days)
TF2<insert size> 30
30
30 single items
(once every 28 days)
TF3<insert size> 30
30
30 single items
(once every 28 days)
220<insert size>
30
30 single items
(once every 28 days)
221<insert size>
30
30 single items
(once every 28 days)
3 of 4 | P a g e
Brand (Supplier)
Coloplast Conveen Security Plus Leg Bag
Conveen Activa
Product Size
Code
Pack Size
Recommendation
5164
5165
5160
5161
25501
10
10
10 bags (every 8 weeks)
10 bags (every 8 weeks)
10 bags (every 8 weeks)
10 bags (every 8 weeks)
10 bags (every 8 weeks)
Small
Large
1450
20
20 at a time as requested
1451
20
20 at a time as requested
500ml
1000ml
9822
10
10 at a time as requested
9821
10
10 at a time as requested
1 control unit, 2 rectal
catheters, 1 water bag, 1
strap set, 1 toilet bag
1 control unit, 2 small
rectal catheters, 1 water
bag, 1 strap set, 1 toilet bag
15 rectal catheters, 1 water
bag
15 small rectal catheters, 1
water bag
10 rectal catheters
29121
1
29126
1
29122
1
29127
1
350ml 30cm
350ml 50cm
500ml 30cm
500ml 50cm
250ml 7cm adjustable inlet tube
10
10
10
Quantity
Anal plugs
Peristeen Anal Plug
Peristeen Anal Plug
Faecal collectors
Hollister 50cm tubing non sterile
Hollister 50cm tubing non sterile
Anal irrigation
Coloplast Peristeen anal
irrigation
Manfred Sauer Qufora Toilet
System
29123
1
10 small rectal catheters
29128
1
1 set of straps
29124
1
2 tubes and blue connectors
29125
1
Qufora Starter Set
(pump, water bag, 5 cones,
5 waste bags, toilet bag)
Qufora monthly set (pump,
water bag, 15 cones, 15
waste bags, toilet bag)
Bed system (pump, water
bag, 5 rectal catheters, 5
collection bags)
Mini Set (1 hand pump, 15
cones)
QTS
1
QTM
1
53201-055(12mm)
53001-055(21mm)
53101-055(30mm)
1
53601 - 015
1
As required following
individual patient assessment
Continence appliances
Beambridge
Manfred Sauer
Male Draining Jug with tap
Female Saddle Urinal
Lady Jug
Bridge Urinal
Funnel
Uribag (male)
Uribag (female)
6-50T
1
1 single unit
6-26
1
1 single unit
6-45
1
1 single unit
6-18
1
1 single unit
6-35
1
1 single unit
URIbag
1
1 single unit
URIbagF
1
1 single unit
Summary of assessment (if applicable)
Requestors Name
Designation
Contact number
Date
4 of 4 | P a g e