Continence Prescription Request Form 2 of 3 – Leg bag holders, leg bags,
bed bags, sheaths, anal plugs, faecal collectors and continence appliances
Patient Details
Name:
Date of Birth:
Hospital/NHS Number:
Address:
Quantity for supply
Prescription to usual pharmacy?
Yes
No Details:
Home delivery required?
Brand (Supplier)
Leg bag holders
Initial supply
Repeat supply
x 4 units (every 4 months) Bard Urisleeve leg bag
holder
Product Size
Small 24 – 39cm
Medium 36 – 55cm
Large 40 – 70cm
Code
15011
150121
150131
Details of person requesting prescription
Name:
Position:
Working base:
Quantity for supply
Phone number:
Email:
Date of request:
Brand (Supplier)
Product Size
Sheaths and leg bags
Initial supply
Repeat supply
1x30 single items (every month) Manfred Sauer PSmall: 20, 22, 24mm
Sure (latex free,
1x30 single items (every month) self-adhesive
Medium: 26, 28, 30mm
sheath, standard
1x30 single items (every month) length only)
Large: 32, 35, 37, 40mm
Code
97.
<insert size>
97.
<insert size>
97.
<insert size>
Extra Large 65 – 95cm
Urinary catheter leg bags
Slide action tap
Initial supply
Repeat supply
x 10 bags (every 2 months) Simpla Trident T1 Short Tube 350ml Leg Bag
x 10 bags (every 2 months) Simpla Trident T1 Short Tube 500ml Leg Bag
x 10 bags (every 2 months) Simpla Trident T1 Long Tube 500ml Leg Bag
Lever action tap
Initial supply
Repeat supply
x 10 bags (every 2 months) Simpla Trident 2 Short Tube 350ml Leg Bag
x 10 bags (every 2 months) Simpla Trident 2 Short Tube 500ml Leg Bag
x 10 bags (every 2 months) Simpla Trident 2 Long Tube 500ml Leg Bag
Urinary catheter bed bags/2 litre bags
Single Use 2 litre bags (unsterile)
Initial supply
Repeat supply
x 30 bags (every month)
ProSys Non Sterile Night Drainage bag 2L
Drainable 2 litre catheter bags (sterile)
Initial supply
Repeat supply
x 10 bags (every 2 months) Simpla S5 Night Bag
Belly bags
Initial supply
x 3 bags (every 12 weeks)
x 3 bags (every 12 weeks)
Repeat supply
Rusch Belly Bag 1000ml (short outlet tube)
Rusch Belly Bag 1000ml (short outlet tube & sample
port)
x 3 bags (every 12 weeks)
Rusch Belly Bag (extra-long (60cm) outlet tube for
wheelchair users)
Anal plugs
Initial supply
Repeat supply
20 at a time as requested
Coloplast Peristeen Anal Plug
Small
Large
Faecal collectors
Initial supply
Repeat supply
10 at a time as requested
Hollister 50cm tubing
500ml
1000ml
Version: 2.1
150141
370802
370807
370817
376137
376138
376139
PSU2
346145
B1000
B1000P
B1000CT
1450
1451
9822
9821
Page 1of 1
1x30 single item (every month)
Style 1 Standard Length
(9cm): 25, 29, 32, 36, 41mm
1x30 single items (every month)
Style 2 Shorter Length:
25, 29, 32, 36, 41mm
1x30 single items (every month)
Style 3 Standard Length,
(extra wide adhesive)
25, 29, 32, 36, 41mm
1x30 single items (every month) Conveen Optima
Standard Length:
(latex free self –
25, 30, 35, 40mm
1x30 single items (every month) adhesive sheath)
Shorter Length:
21, 25, 30, 35mm
x 10 bags (every 2 months)
Coloplast
350ml 30cm
Conveen Security 350ml 50cm
Plus Leg Bag
500ml 30cm
500ml 50cm
x 10 bags (every 2 months)
Coloplast
250ml (7cm adjustable inlet
Conveen Active
tube)
Continence appliances
Initial supply
Repeat supply
1 single unit
Beambridge Male Draining
6-50T
Jug with tap
1 single unit
Beambridge Female Saddle
6-26
Urinal
1 single unit
Beambridge Lady Jug
6-45
1 single unit
1 single unit
1 single unit
1 single unit
Rochester
Freedom Transfix
(100% clear
silicone sheath)
Beambridge Bridge Urinal
Beambridge Funnel
Manfred Sauer Uribag
Manfred Sauer Uribag
6-18
6-35
Male
Female
30
TF1
<insert size>
30
TF2
<insert size>
TF3
<insert size> 30
220
<insert size>
221
<insert size>
5164
5165
5160
5161
25501
1
1
1
1
1
URIbag
URIbagF
Developed: March 2015; Review date: October 2016