Continence Prescription Request Form 3 of 3 – specialist initiation products
By Bladder and Bowel Specialist Nurses, Urology Specialist Nurses and Urologists.
Patient Details
Name:
Date of Birth:
Hospital/NHS Number:
Address:
Prescription to usual pharmacy?
Yes
No Details:
Home delivery required?
Quantity for supply
Urinary catheters
Silicone – Male
Brand (Supplier)
Product Size
Code
Rusch Brilliant Silflate
12
Coloplast Folysil
(standard length only)
14 16
Male DG3101
Female DG2101
AA8C
<insert size>
<insert size>
<insert size>
12 14 16 18
x 2 units repeat supply
Silver alloy coated – Male
x 3 units initial supply
Female
Bardex I.C. Foley
Catheter
12 14 16
18* 20* 22*
* Male only
x 2 units repeat supply
Catheter tube restraining straps -
Initial supply
Male D2365
<insert size>
Female D2369
Quantity for supply
Brand (Supplier)
Product Size
10645B
383003
PHN
PHW
851241
904000 - 904800
OS4010-18
CL10-CL-14
228010E-228014E
630106-630114
Intermittent urinary catheters (with bags) - Initial supply
Repeat supply
Individual assessment (6-8
Actreen Glys Set male (with bag)
226208E – 226218E
daily)
Actreen Glys Set female (with bag)
226306E – 226316E
<insert quantity>
Hollister Advance Plus (with bag)
92084 – 92184
LoFric Hydro-kit Male (non PVC)
: waist 2X (44”-46”)
9 single units
(per year)
Female
Clinimed Curan Lady
B.Braun Actereen Mini
Teleflex Liquick Base
Male Dilator - Initial supply
Repeat supply
Individual assessment
Peak Medical Ltd Ultra Smooth Metal Dilator
Afex Accessories
x 1 single unit
Afex Active Starter Pack
x 1 single unit
Afex Sedentary Starter Pack
x 1 single unit
Afex Mobility Assisted Starter Pack
Afex Accessories Initial supply
Repeat supply
4 single units
Briefs: waist S (28”-30”)
/ M (32”-34”)
(per year)
: waist L (36”-38”)
/ XL (40”-42”)
<insert size>
Repeat supply
x 5 units (4 monthly)
Great Bear Fix It (abdominal strap)
x 5 units (4 monthly)
Simpla G Strap (abdominal strap)
Miscellaneous catheter supplies - Initial supply
Repeat supply
x 1 single unit
Manfred Sauer p.hold 2cm (Penis Holder)
x 1 single unit
Manfred Sauer p.hold 4cm (Penis Holder)
Intermittent urinary catheters - Initial supply
Repeat supply
Male
Individual assessment
Rusch Teleflex Flocath Quick
(average 6-8 daily)
Wellspect Healthcare LoFric Plus
<insert quantity>
Optismooth Hydrophilic
Individual assessment
(average 6-8 daily)
<insert quantity>
Position:
Working base:
Phone number:
Email:
Date of request:
Tiemann tip Initial supply
Repeat supply
Individual assessment
Teleflex male Tiemann Tip Liquick Base
Female
x 3 units initial supply
x 2 units repeat supply
Open ended silicone
x 3 units initial supply
Details of person requesting prescription
Name:
4200825 - 4201825
Urine Bags: 500ml vented
Page 1of 1
A100-Plus brief code
A110-Plus brief code
A120-Plus brief code
A200-S-08
/ A200-M-08
A200-L-08 / A200-XL-08
A200-2X-08 / A200-3X-08
A400-V-08 / A400-B-08
10 small rectal catheters
A400-L-08
A400-E-08
A400-X-08
A300-L-08 / A300-S-08
A300-F-08
A700-A-08
A700-S-07
A710-S-09
29121
29126
29122
29127
29123
1 set of straps
29124
2 tubes and blue connectors
29125
/
29128
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)
QTS
Bed system (pump, water bag, 5 rectal catheters, 5
collection bags)
53201-055(12mm)
53001-055(21mm)
53101-055(30mm)
53601 - 015
Mini Set (1 hand pump, 15 cones)
Version: 2.1
USMD08-18
/ 500ml unvented
10 rectal catheters /
Manfred
Sauer
Qufora
Toilet
System
631012-16
/ 3X (48”-50”)
:1200ml leg bag
:Extra capacity
:2000ml bed bag
3 single units
Receptacles : Low
/ Low supersoft receptacle
(per year)
: High receptacle
9 single units (per year)
Extension tubes & stabilisers: Tube assembly complete
Individual assessment
:Tube stabiliser
Individual assessment
:Bag stabiliser-high grip
Anal irrigation - Initial supply
Repeat supply
1 control unit, 2 rectal catheters, 1 water bag, 1
Coloplast
strap set, 1 toilet bag
Peristeen
1 control unit, 2 small rectal catheters, 1 water bag,
anal
As required following
1 strap set, 1 toilet bag
irrigation
15 rectal catheters, 1 water bag
individual patient
15 small rectal catheters, 1 water bag
assessment
<insert quantity>
Code
QTM
Developed: March 2015; Review date: October 2016